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General NPI Number Information
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NPI Number | 1174711758
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Entity Type | Organization
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Legal Business Name | RSM PA PLLC
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Dates
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Enumeration Date | 10/09/2007
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Last Update Date | 10/09/2007
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Provider Practice Location Address
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Address Line | 1595 BANNOCK HWY
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City | POCATELLO
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State | ID
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Zip | 83204
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Country | US
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Telephone | 208-238-0400
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Fax | 208-238-0401
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Provider Business Mailing Address
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Address Line | 1595 BANNOCK HWY
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City | POCATELLO
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State | ID
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Zip | 83204
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Country | US
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Telephone | 208-238-0400
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Fax | 208-238-0401
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Authorized Official
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Title or Position | OWNER
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Name | ROGER SCOTT MALM
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Credential | PA
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Telephone | 208-238-0400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA220
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License Number State | ID
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