Healthcare Provider Details

I. General information

NPI: 1972545556
Provider Name (Legal Business Name): FAMILY MEDICAL CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 02/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 E LIBERTY ST
WEISER ID
83672-2261
US

IV. Provider business mailing address

360 E LIBERTY ST
WEISER ID
83672-2261
US

V. Phone/Fax

Practice location:
  • Phone: 208-414-1124
  • Fax: 208-414-0947
Mailing address:
  • Phone: 208-414-1124
  • Fax: 208-414-0947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BRYAN L DRAKE
Title or Position: PARTNER
Credential: D.O.
Phone: 208-414-1124