MEDICARE: SPARKMD

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	261QP2300X	Primary Care Clinic/Center	M-10803	ID

General Provider Information

NPI Number	:	1427443613
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPARKMD

Provider Business Mailing Address
First Line	:	302 W IDAHO ST
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83702-6039
Country	:	US
Telephone Number	:	208-369-4590
Fax Number	:

Provider Business Practice Location Address
First Line	:	302 W IDAHO ST
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83702-6039
Country	:	US
Telephone Number	:	208-369-4590
Fax Number	:

Authorized Official
Title or Position	:	OWNER, PHYSICIAN
Name	:	DR. JULIE KRISTEN GUNTHER
Credential	:	MD, FAAFP
Telephone Number	:	208-369-4590

Provider Enumeration Date	:	04/03/2015
Last Update Date	:	04/21/2015

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