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General NPI Number Information
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NPI Number | 1003157801
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Entity Type | Organization
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Legal Business Name | IDAHO REGIONAL HAND & UPPER EXTREMITY CENTER PLLC
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Dates
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Enumeration Date | 03/05/2013
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Last Update Date | 08/30/2018
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Provider Practice Location Address
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Address Line | 444 HOSPITAL WAY STE 710
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City | POCATELLO
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State | ID
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Zip | 83201
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Country | US
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Telephone | 208-235-4263
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Fax | 208-233-4268
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Provider Business Mailing Address
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Address Line | 444 HOSPITAL WAY STE 710
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City | POCATELLO
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State | ID
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Zip | 83201-2745
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Country | US
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Telephone | 208-235-4263
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Fax | 208-233-4268
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JEFFREY DEE STUCKI
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Credential | DO
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Telephone | 208-235-4263
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207XS0106X
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Taxonomy Name | Orthopaedic Hand Surgery Physician
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License Number | M-8547
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA-684
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License Number State | ID
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Taxonomy #3
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Taxonomy Code | 207XS0106X
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Taxonomy Name | Orthopaedic Hand Surgery Physician
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License Number | O-0574
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License Number State | ID
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