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General NPI Number Information
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NPI Number | 1376362038
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Entity Type | Organization
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Legal Business Name | PEDIATRIC CARDIOLOGY OF IDAHO
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Dates
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Enumeration Date | 10/08/2024
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Last Update Date | 10/08/2024
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Provider Practice Location Address
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Address Line | 900 N LIBERTY ST STE 206
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City | BOISE
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State | ID
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Zip | 83704-8729
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Country | US
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Telephone | 208-453-9962
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Fax | 208-453-9963
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Provider Business Mailing Address
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Address Line | 2225 E SOLITUDE CT
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City | BOISE
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State | ID
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Zip | 83712-7576
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Country | US
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Telephone | 208-453-9962
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | WHITNEY BAIRD
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Credential |
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Telephone | 208-453-9962
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080P0202X
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Taxonomy Name | Pediatric Cardiology Physician
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License Number |
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License Number State |
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