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General NPI Number Information
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NPI Number | 1417737594
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Entity Type | Organization
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Legal Business Name | MOMENTUM MEDICAL GROUP OF IDAHO LLC
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Dates
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Enumeration Date | 10/04/2023
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Last Update Date | 01/10/2024
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Provider Practice Location Address
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Address Line | 8854 W EMERALD ST STE 275
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City | BOISE
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State | ID
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Zip | 83704-4860
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Country | US
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Telephone | 208-375-3201
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Fax |
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Provider Business Mailing Address
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Address Line | 8854 W EMERALD ST STE 140
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City | BOISE
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State | ID
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Zip | 83704-4845
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | BILLING SERVICE
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Name | HEATHER BEARD
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Credential |
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Telephone | 208-880-0883
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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