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General NPI Number Information
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NPI Number | 1487151882
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Entity Type | Organization
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Legal Business Name | PAGE FAMILY MEDICINE
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Dates
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Enumeration Date | 04/11/2018
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Last Update Date | 02/01/2019
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Provider Practice Location Address
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Address Line | 1252 BENNETT AVE SUITE B
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City | BURLEY
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State | ID
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Zip | 83318
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Country | US
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Telephone | 208-617-0656
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Fax | 208-647-0659
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Provider Business Mailing Address
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Address Line | 260 FALLS AVE STE C
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City | TWIN FALLS
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State | ID
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Zip | 83301-3370
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Country | US
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Telephone | 208-736-7422
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Fax | 708-736-8905
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | JEREMY B HAYMORE
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Credential | MD
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Telephone | 208-312-2242
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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-4391
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License Number State | ID
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