Healthcare Provider Details

I. General information

NPI: 1174711758
Provider Name (Legal Business Name): RSM PA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1595 BANNOCK HWY
POCATELLO ID
83204
US

IV. Provider business mailing address

1595 BANNOCK HWY
POCATELLO ID
83204
US

V. Phone/Fax

Practice location:
  • Phone: 208-238-0400
  • Fax: 208-238-0401
Mailing address:
  • Phone: 208-238-0400
  • Fax: 208-238-0401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA220
License Number StateID

VIII. Authorized Official

Name: ROGER SCOTT MALM
Title or Position: OWNER
Credential: PA
Phone: 208-238-0400