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General NPI Number Information
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NPI Number | 1952335929
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Entity Type | Organization
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Legal Business Name | PIONEER FAMILY MEDICINE PLLC
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Dates
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Enumeration Date | 07/10/2006
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Last Update Date | 08/23/2019
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Provider Practice Location Address
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Address Line | 4740 N. PENNGROVE WAY STE. 100
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City | MERIDIAN
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State | ID
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Zip | 83646
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Country | US
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Telephone | 208-938-3663
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Fax | 208-938-3664
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Provider Business Mailing Address
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Address Line | 4740 N. PENNGROVE WAY STE. 100
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City | MERIDIAN
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State | ID
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Zip | 83646
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Country | US
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Telephone | 208-938-3663
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Fax | 208-938-3664
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Authorized Official
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Title or Position | OWNER
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Name | JASON SCOTT LUDWIG
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Credential | DO
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Telephone | 208-938-3663
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | O-253
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License Number State | ID
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