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General NPI Number Information
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NPI Number | 1356475115
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Entity Type | Organization
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Legal Business Name | MICHAEL P KOELSCH MD
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Dates
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Enumeration Date | 03/15/2007
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Last Update Date | 09/20/2013
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Provider Practice Location Address
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Address Line | 805 N 6TH E
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City | MOUNTAIN HOME
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State | ID
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Zip | 83647-2207
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Country | US
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Telephone | 208-587-5880
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Fax | 208-587-7905
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Provider Business Mailing Address
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Address Line | PO BOX 940
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City | MOUNTAIN HOME
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State | ID
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Zip | 83647-0940
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Country | US
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Telephone | 208-587-5880
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Fax | 208-587-7905
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MARY LOU KOELSCH
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Credential |
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Telephone | 208-587-5880
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | NP382A
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | M3819
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License Number State | ID
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