Healthcare Provider Details

I. General information

NPI: 1265670061
Provider Name (Legal Business Name): M ELIZABETH GERARD MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2009
Last Update Date: 06/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 N 18TH AVE STE B4
POCATELLO ID
83201
US

IV. Provider business mailing address

333 N 18TH AVE STE B4
POCATELLO ID
83201
US

V. Phone/Fax

Practice location:
  • Phone: 208-232-2233
  • Fax: 208-232-2299
Mailing address:
  • Phone: 208-232-2233
  • Fax: 208-232-2299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberM-7059
License Number StateID

VIII. Authorized Official

Name: M ELIZABETH GERARD
Title or Position: OWNER
Credential: M.D.
Phone: 208-233-8344