MEDICARE: CITY OF TROY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3416L0300X	Land Ambulance	12345	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12345	OTHER	ID	STATE LICENSE

General Provider Information

NPI Number	:	1023393709
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITY OF TROY

Provider Business Mailing Address
First Line	:	PO BOX 324
Second Line	:
City	:	TROY
State	:	ID
Zip	:	83871
Country	:	US
Telephone Number	:	208-596-6384
Fax Number	:

Provider Business Practice Location Address
First Line	:	521 EAGLE ALLEY
Second Line	:
City	:	TROY
State	:	ID
Zip	:	83871
Country	:	US
Telephone Number	:	208-596-6384
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DONNA OPESIK
Credential	:
Telephone Number	:	208-596-6384

Provider Enumeration Date	:	10/13/2011
Last Update Date	:	10/13/2011

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Directions to “CITY OF TROY ” Practice Location

Language	Start Address	Practice Location

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