MEDICARE: DR. BRYAN C POGUE SR. 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
1	207Q00000X	Family Medicine Physician	M5125	ID

General Provider Information

NPI Number	:	1740286723
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRYAN C POGUE SR. MD

Provider Business Mailing Address
First Line	:	215 E HAWAII AVE
Second Line	:
City	:	NAMPA
State	:	ID
Zip	:	83686-6011
Country	:	US
Telephone Number	:	208-463-3000
Fax Number	:	208-463-3308

Provider Business Practice Location Address
First Line	:	9850 ST LUKES DR
Second Line	:
City	:	NAMPA
State	:	ID
Zip	:	83687-7912
Country	:	US
Telephone Number	:	208-463-3000
Fax Number	:	208-288-4951

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

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	05/29/2018

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