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General NPI Number Information
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NPI Number | 1679103485
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Entity Type | Organization
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Legal Business Name | SHH MEDICAL GROUP NORTH IDAHO, LLC
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Dates
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Enumeration Date | 01/21/2020
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Last Update Date | 01/21/2020
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Provider Practice Location Address
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Address Line | 1221 W IRONWOOD DR STE 102
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City | COEUR D ALENE
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State | ID
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Zip | 83814-1402
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Country | US
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Telephone | 208-773-7731
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Fax | 208-665-8112
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Provider Business Mailing Address
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Address Line | PO BOX 1176
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City | MERIDIAN
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State | ID
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Zip | 83680-1176
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Country | US
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Telephone | 208-376-7298
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Fax | 208-377-8310
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Authorized Official
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Title or Position | PRESIDENT
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Name | JASON FLETCHER
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Credential |
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Telephone | 208-376-7298
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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