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General NPI Number Information
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NPI Number | 1154356624
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Entity Type | Organization
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Legal Business Name | IDAHO SPORTS MEDICINE INSTITUTE, PA
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Dates
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Enumeration Date | 07/12/2006
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Last Update Date | 02/25/2011
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Provider Practice Location Address
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Address Line | 1188 UNIVERSITY DR
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City | BOISE
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State | ID
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Zip | 83706-3009
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Country | US
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Telephone | 208-336-8250
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Fax | 208-345-9514
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Provider Business Mailing Address
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Address Line | 1188 UNIVERSITY DR
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City | BOISE
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State | ID
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Zip | 83706-3009
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Country | US
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Telephone | 208-336-8250
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Fax | 208-345-9514
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Authorized Official
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Title or Position | OWNER/PARTNER
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Name | JENNIFER R. MILLIER
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Credential | M.D.
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Telephone | 208-336-8250
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 204C00000X
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Taxonomy Name | Sports Medicine (Neuromusculoskeletal Medicine) Physician
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License Number | N/A FOR GROUP
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License Number State |
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