Basic Information
| Provider Information | |||||||||
| NPI: | 1972808806 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PSYCHIATRY-ECT, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 285 VISTA DR | ||||||||
| Address2: | SUITE D | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082338344 | ||||||||
| FaxNumber: | 2082336983 | ||||||||
| Practice Location | |||||||||
| Address1: | 285 VISTA DR | ||||||||
| Address2: | SUITE D | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082338344 | ||||||||
| FaxNumber: | 2082336983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2011 | ||||||||
| LastUpdateDate: | 01/25/2011 | ||||||||
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| AuthorizedOfficialLastName: | GLIGOROVIC | ||||||||
| AuthorizedOfficialFirstName: | PREDRAG | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2082338344 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | M-9600 | ID | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.