Provider Demographics
NPI:1174939383
Name:MAGIC VALLEY MEDICINE PLLC
Entity type:Organization
Organization Name:MAGIC VALLEY MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:H
Authorized Official - Last Name:BARKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-734-0000
Mailing Address - Street 1:844 WASHINGTON ST N STE 400
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3874
Mailing Address - Country:US
Mailing Address - Phone:208-734-0000
Mailing Address - Fax:208-735-5053
Practice Address - Street 1:844 WASHINGTON ST N STE 400
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3874
Practice Address - Country:US
Practice Address - Phone:208-734-0000
Practice Address - Fax:208-735-5053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-08
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1174939383Medicaid
7369300001OtherMEDICARE DME
20005523Medicare PIN