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General NPI Number Information
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NPI Number | 1982632550
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Entity Type | Organization
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Legal Business Name | FAMILY PRACTICE RESIDENCY OF IDAHO, INC
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Dates
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Enumeration Date | 06/30/2006
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Last Update Date | 01/30/2008
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Provider Practice Location Address
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Address Line | 777 N RAYMOND ST
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City | BOISE
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State | ID
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Zip | 83704-9251
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Country | US
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Telephone | 208-367-6030
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Fax | 208-367-6123
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Provider Business Mailing Address
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Address Line | 777 N RAYMOND ST
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City | BOISE
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State | ID
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Zip | 83704-9251
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Country | US
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Telephone | 208-367-6030
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Fax | 208-367-6123
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Authorized Official
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Title or Position | CHAIRMAN AND PROGRAM DIRECTOR
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Name | TED EPPERLY
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Credential | M.D.
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Telephone | 208-367-6042
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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 |
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License Number State |
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