Healthcare Provider Details

I. General information

NPI: 1336214618
Provider Name (Legal Business Name): IDAHO STATE UNIVERSITY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 02/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

990 CESAR CHAVEZ AVE
POCATELLO ID
83209-0001
US

IV. Provider business mailing address

921 S 8TH AVE STOP 8311
POCATELLO ID
83209-0002
US

V. Phone/Fax

Practice location:
  • Phone: 208-282-2330
  • Fax: 208-282-4036
Mailing address:
  • Phone: 208-282-2330
  • Fax: 208-282-4036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. RONALD M SOLBRIG
Title or Position: DIRECTOR
Credential: MD
Phone: 208-282-2330