=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992853386
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GEM STATE PEDIATRICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 520 S EAGLE RD SUITE 1209
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-6308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-706-5460
-----------------------------------------------------
Fax | 208-706-5465
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 520 S EAGLE RD SUITE 1209
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-6308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-706-5460
-----------------------------------------------------
Fax | 208-706-5465
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARIO BRUS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 208-706-5460
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | M5562
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------