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General NPI Number Information
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NPI Number | 1124115944
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Entity Type | Organization
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Legal Business Name | TONY C ROISUM MD PA
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Dates
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Enumeration Date | 10/05/2006
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Last Update Date | 05/20/2016
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Provider Practice Location Address
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Address Line | 3360 WASHINGTON PKWY SUITE 1
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City | IDAHO FALLS
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State | ID
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Zip | 83404-8333
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Country | US
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Telephone | 208-524-3416
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Fax | 208-524-3138
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Provider Business Mailing Address
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Address Line | 3360 WASHINGTON PKWY SUITE 1
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City | IDAHO FALLS
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State | ID
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Zip | 83404-8333
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Country | US
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Telephone | 208-524-3416
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Fax | 208-524-3138
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Authorized Official
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Title or Position | OWNER / PRESIDENT
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Name | TONY C ROISUM
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Credential | MD
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Telephone | 208-524-3416
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QS0010X
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Taxonomy Name | Sports Medicine (Family Medicine) Physician
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License Number | M7389
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | M7389
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License Number State | ID
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