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General NPI Number Information
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NPI Number | 1255621835
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Entity Type | Organization
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Legal Business Name | TAMARACK EAGLE MEDICAL
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Dates
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Enumeration Date | 04/15/2011
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Last Update Date | 04/15/2011
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Provider Practice Location Address
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Address Line | 311 VILLAGE DR
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City | TAMARACK
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State | ID
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Zip | 83615-5014
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Country | US
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Telephone | 208-724-7420
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Fax |
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Provider Business Mailing Address
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Address Line | 5701 WILLOW CREEK RD
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City | EAGLE
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State | ID
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Zip | 83616-2025
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Country | US
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Telephone | 208-724-7420
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | DR. ROURKE YEAKLEY
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Credential | M.D.
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Telephone | 208-724-7420
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | M8190
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License Number State | ID
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