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General NPI Number Information
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NPI Number | 1285797241
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Entity Type | Individual
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Provider Name | ROGER W. BOE M.D.
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Gender | Male
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Dates
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Enumeration Date | 12/19/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 405 W WHITMAN ST
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City | POCATELLO
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State | ID
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Zip | 83204-3317
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Country | US
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Telephone | 208-233-6833
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Fax |
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Provider Business Mailing Address
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Address Line | 226 S 16TH AVE
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City | POCATELLO
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State | ID
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Zip | 83201-4003
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Country | US
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Telephone | 208-233-5651
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080A0000X
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Taxonomy Name | Pediatric Adolescent Medicine Physician
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License Number | M2691
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License Number State | ID
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