Healthcare Provider Details

I. General information

NPI: 1346391513
Provider Name (Legal Business Name): STEPHEN J. CHEYNE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 N BRIDGE ST
SAINT ANTHONY ID
83445-1425
US

IV. Provider business mailing address

PO BOX 37
SAINT ANTHONY ID
83445-0037
US

V. Phone/Fax

Practice location:
  • Phone: 208-624-4402
  • Fax: 208-624-4409
Mailing address:
  • Phone: 208-624-4402
  • Fax: 208-624-4409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberM4566
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: