MEDICARE: EMERGENCY MEDICINE OF IDAHO

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	207P00000X	Emergency Medicine Physician		ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000010148698	OTHER	ID	REGENCE BLUE SHIELD IF ID
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	8K743	OTHER	ID	BLUE CROSS OF IDAHO

General Provider Information

NPI Number	:	1205875275
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMERGENCY MEDICINE OF IDAHO

Provider Business Mailing Address
First Line	:	3080 E GENTRY WAY STE 210
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83642-3013
Country	:	US
Telephone Number	:	208-615-8201
Fax Number	:	208-779-2971

Provider Business Practice Location Address
First Line	:	3080 E GENTRY WAY STE 210
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83642-3013
Country	:	US
Telephone Number	:	208-615-8201
Fax Number	:	208-779-2971

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	JOHN DAVID BISHOP
Credential	:
Telephone Number	:	208-615-8201

Provider Enumeration Date	:	06/05/2006
Last Update Date	:	02/21/2025

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Directions to “EMERGENCY MEDICINE OF IDAHO ” Practice Location

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