MEDICARE: DR. BRUCE E. GOLLUB M.D.

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	207Q00000X	Family Medicine Physician	80-158	NM
2	208D00000X	General Practice Physician	80-158	NM
3	207Q00000X	Family Medicine Physician	M-17332	ID

Other Identifiers

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

General Provider Information

NPI Number	:	1508855917
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRUCE E. GOLLUB M.D.

Provider Business Mailing Address
First Line	:	190 E BANNOCK ST
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83712-6241
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	775 POLE LINE RD W STE 103
Second Line	:
City	:	TWIN FALLS
State	:	ID
Zip	:	83301-5819
Country	:	US
Telephone Number	:	208-814-8375
Fax Number	:	208-814-8376

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/18/2005
Last Update Date	:	11/30/2023

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