=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215191390
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SWENSON M.D. INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2008
-----------------------------------------------------
Last Update Date | 07/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1218 9TH ST STE 4
-----------------------------------------------------
City | RUPERT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83350-2207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-436-4838
-----------------------------------------------------
Fax | 208-436-1561
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1218 9TH ST STE 4
-----------------------------------------------------
City | RUPERT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83350-2207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-436-4838
-----------------------------------------------------
Fax | 208-436-1561
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JEFFREY SCOTT SWENSON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 208-436-4838
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | M9766
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------