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General NPI Number Information
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NPI Number | 1467963496
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Entity Type | Organization
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Legal Business Name | KURT E KRACAW MD LLC
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Dates
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Enumeration Date | 10/17/2017
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Last Update Date | 04/03/2018
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Provider Practice Location Address
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Address Line | 426 FARNSWORTH WAY STE 1
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City | RIGBY
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State | ID
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Zip | 83442-4713
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Country | US
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Telephone | 208-745-9411
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Fax | 208-745-9910
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Provider Business Mailing Address
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Address Line | PO BOX 3208
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City | IDAHO FALLS
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State | ID
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Zip | 83403-3208
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Country | US
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Telephone | 208-523-4906
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Fax | 208-523-2025
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Authorized Official
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Title or Position | OWNER
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Name | DR. KURT EDWIN KRACAW
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Credential | MD
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Telephone | 775-772-4208
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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 | M-13115
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License Number State | ID
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