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NPI Code Detail

MEDICARE: MEDICAL CENTER FOR CHILDREN & ADOLESCENTS, PA

MEDICARE: MEDICAL CENTER FOR CHILDREN & ADOLESCENTS, PA
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
1208000000XPediatrics Physician

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1000010006561OTHERIDBLUE SHIELD
285456OTHERIDBLUE CROSS

General Provider Information

NPI Number : 1073528998
Entity Type Code : Organization
Provider Name (Legal Business Name) : MEDICAL CENTER FOR CHILDREN & ADOLESCENTS, PA
Provider Business Mailing Address
First Line : 3430 WASHINGTON PKWY
Second Line :
City : IDAHO FALLS
State : ID
Zip : 83404-7579
Country : US
Telephone Number : 208-523-3060
Fax Number :
Provider Business Practice Location Address
First Line : 3430 WASHINGTON PKWY
Second Line :
City : IDAHO FALLS
State : ID
Zip : 83404-7579
Country : US
Telephone Number : 208-523-3060
Fax Number :
Authorized Official
Title or Position : PRESIDENT
Name : DR. MICHAEL JUDE PANKAU
Credential : M.D.
Telephone Number : 208-523-3060
Provider Enumeration Date : 07/29/2006
Last Update Date : 08/22/2020

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Directions to “MEDICAL CENTER FOR CHILDREN & ADOLESCENTS, PA ” Practice Location

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