=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104938182
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT LOUIS CORAY M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 10/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 859 S YELLOWSTONE HWY STE 3301
-----------------------------------------------------
City | REXBURG
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83440-6200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-356-9086
-----------------------------------------------------
Fax | 208-369-4498
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 859 S YELLOWSTONE HWY STE 3301
-----------------------------------------------------
City | REXBURG
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83440-6200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-356-9086
-----------------------------------------------------
Fax | 208-369-4498
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | M7679
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------