=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922110188
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC GERAND STACKLE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2429 NORTH COLE ROAD
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83704-5907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-377-4190
-----------------------------------------------------
Fax | 208-358-9157
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2429 NORTH COLE ROAD
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83704-5907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-377-4190
-----------------------------------------------------
Fax | 208-358-9157
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | M3313
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------