=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801891569
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MONIKA GERDA FEALKO MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2005
-----------------------------------------------------
Last Update Date | 09/02/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 333 N. FIRST ST SUITE 240
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-338-8900
-----------------------------------------------------
Fax | 208-331-2418
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 333 N. FIRST ST SUITE 240
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-338-8900
-----------------------------------------------------
Fax | 208-331-2418
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 35079854F
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | M-10332
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------