Provider Demographics
NPI:1730133208
Name:IDAHO EMERGENCY PHYSICIANS, P.A.
Entity type:Organization
Organization Name:IDAHO EMERGENCY PHYSICIANS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN AND PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:WILIDING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-322-1730
Mailing Address - Street 1:PO BOX 5666
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-5666
Mailing Address - Country:US
Mailing Address - Phone:208-322-1730
Mailing Address - Fax:208-322-1731
Practice Address - Street 1:2963 E COPPER POINT DR
Practice Address - Street 2:SUITE 150
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-9055
Practice Address - Country:US
Practice Address - Phone:208-322-1730
Practice Address - Fax:208-322-1731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002426500Medicaid
ID002426500Medicaid