MEDICARE: MAGIC VALLEY UROLOGY PLLC

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	208800000X	Urology Physician

General Provider Information

NPI Number	:	1790388700
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGIC VALLEY UROLOGY PLLC

Provider Business Mailing Address
First Line	:	2114 VILLAGE PARK AVE STE 200
Second Line	:
City	:	TWIN FALLS
State	:	ID
Zip	:	83301-4172
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2114 VILLAGE PARK AVE STE 200
Second Line	:
City	:	TWIN FALLS
State	:	ID
Zip	:	83301-4172
Country	:	US
Telephone Number	:	208-947-5390
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JASON GREENHALGH
Credential	:	MD
Telephone Number	:	208-947-5390

Provider Enumeration Date	:	11/20/2020
Last Update Date	:	11/20/2020

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