=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922366707
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COTTONWOOD FAMILY MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2012
-----------------------------------------------------
Last Update Date | 04/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 COTTONWOOD COURT SUITE 150
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 87616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-995-2875
-----------------------------------------------------
Fax | 208-995-2874
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 COTTONWOOD COURT SUITE 150
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-995-2875
-----------------------------------------------------
Fax | 208-995-2874
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPERATOR
-----------------------------------------------------
Name | MARCIA DEE PRICE-MILLER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 208-995-2875
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------