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General NPI Number Information
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NPI Number | 1639391477
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Entity Type | Organization
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Legal Business Name | TARGHEE INTERNAL MEDICINE
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Dates
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Enumeration Date | 05/02/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 232 E 1ST N
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City | REXBURG
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State | ID
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Zip | 83440-1616
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Country | US
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Telephone | 208-356-7755
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 275
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City | REXBURG
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State | ID
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Zip | 83440-0275
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Country | US
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Telephone | 208-356-7755
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Fax |
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Authorized Official
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Title or Position | SECRETARY- TREASURER
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Name | LIISA OSWALD
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Credential |
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Telephone | 208-356-7755
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084S0012X
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Taxonomy Name | Sleep Medicine (Psychiatry & Neurology) Physician
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License Number | O-305
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License Number State | ID
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