Healthcare Provider Details

I. General information

NPI: 1669490298
Provider Name (Legal Business Name): RUSS MCAFFEE A.T.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 S. 5TH AVE. STE. 140
POCATELLO ID
83201
US

IV. Provider business mailing address

31 HARVARD ST
POCATELLO ID
83201-3419
US

V. Phone/Fax

Practice location:
  • Phone: 208-232-4267
  • Fax:
Mailing address:
  • Phone: 208-681-5852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberAT-187
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: