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NPI Code Detail

MEDICARE: ALVIN JACKSON SECREST III MD

MEDICARE: ALVIN JACKSON SECREST III MD
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
1207Q00000XFamily Medicine PhysicianM6256ID

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1053314864
Entity Type Code : Individual
Provider Name (Legal Business Name) : ALVIN JACKSON SECREST III MD
Provider Business Mailing Address
First Line : PO BOX 565
Second Line :
City : COTTONWOOD
State : ID
Zip : 83522-0565
Country : US
Telephone Number : 208-962-3267
Fax Number : 208-962-2313
Provider Business Practice Location Address
First Line : 701 LEWISTON ST
Second Line :
City : COTTONWOOD
State : ID
Zip : 83522-9750
Country : US
Telephone Number : 208-962-3267
Fax Number : 208-962-2313
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/24/2005
Last Update Date : 08/11/2021

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