=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922237874
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UPPER VALLEY FAMILY PRACTICE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2009
-----------------------------------------------------
Last Update Date | 04/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 32 W 1ST S
-----------------------------------------------------
City | REXBURG
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83440-1810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-356-8883
-----------------------------------------------------
Fax | 208-656-0292
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 32 W 1ST S
-----------------------------------------------------
City | REXBURG
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83440-1810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-356-8883
-----------------------------------------------------
Fax | 208-656-0292
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ PHYSICAN
-----------------------------------------------------
Name | DR. JEFFREY G HOPKIN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 208-356-8883
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | M-6910
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------