Provider Demographics
NPI:1942028592
Name:PRISM FAMILY MEDICINE LLC
Entity type:Organization
Organization Name:PRISM FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROLYNN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-806-4581
Mailing Address - Street 1:1950 E CLARK ST STE 100
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3315
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1950 E CLARK ST STE 100
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3315
Practice Address - Country:US
Practice Address - Phone:208-806-4581
Practice Address - Fax:208-837-3010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-02
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty