=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912743501
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SETH KOYLE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2024
-----------------------------------------------------
Last Update Date | 07/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1501 HILAND AVE
-----------------------------------------------------
City | BURLEY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83318-2688
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-678-4444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1121 DIAMOND DR
-----------------------------------------------------
City | RUPERT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83350-2219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-312-7939
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2081S0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | AT-726
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------