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General NPI Number Information
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NPI Number | 1164539912
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Entity Type | Organization
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Legal Business Name | MOUNTAIN HEALTH SERVICES PC
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Dates
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Enumeration Date | 08/25/2006
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Last Update Date | 02/14/2013
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Provider Practice Location Address
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Address Line | 740 MCKINLEY AVE
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City | KELLOGG
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State | ID
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Zip | 83837-2693
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Country | US
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Telephone | 208-783-1267
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Fax | 208-786-4471
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Provider Business Mailing Address
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Address Line | 740 MCKINLEY AVE
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City | KELLOGG
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State | ID
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Zip | 83837-2693
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Country | US
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Telephone | 208-783-1267
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Fax | 208-786-4471
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | FREDERICK R HALLER
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Credential | M.D.
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Telephone | 208-783-1267
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | M8355
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License Number State | ID
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