=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619430303
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HAILEY N. BAISCH MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2019
-----------------------------------------------------
Last Update Date | 07/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 450 W STATE ST STE 100
-----------------------------------------------------
City | EAGLE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83616-7055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-939-1035
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 190 E BANNOCK ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83712-6241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 11924118-1205
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | M-16659
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------