Basic Information
Provider Information | |||||||||
NPI: | 1508003104 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ROCKY MOUNTAIN EMERGENCY PHYSICIANS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 15070 | ||||||||
Address2: |   | ||||||||
City: | SCOTTSDALE | ||||||||
State: | AZ | ||||||||
PostalCode: | 852675070 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4804219700 | ||||||||
FaxNumber: | 4804219899 | ||||||||
Practice Location | |||||||||
Address1: | 777 HOSPITAL WAY | ||||||||
Address2: |   | ||||||||
City: | POCATELLO | ||||||||
State: | ID | ||||||||
PostalCode: | 83201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4804219799 | ||||||||
FaxNumber: | 4804219899 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/19/2009 | ||||||||
LastUpdateDate: | 05/11/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FOWLER | ||||||||
AuthorizedOfficialFirstName: | RANDALL | ||||||||
AuthorizedOfficialMiddleName: | SCOTT | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2082391111 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | M4363 | ID | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
ID | Type | State | Issuer | Description | M4363 | 01 | ID | LICNESE NUMBER | OTHER | 8N801 | 01 | ID | BLUE CROSS | OTHER |