NPIMap

Organization Active NPI

Idaho Street Medical Clinic

  • Rural Health Clinic/Center
  • Homedale, ID
National Provider Identifier
1063970143
Registry record updated Mar 7, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
IDAHO STREET MEDICAL CLINIC
Practice address
126 Idaho Ave.
Homedale, ID 83628-8362
Phone
(208) 859-4103
NPI assigned
Mar 7, 2019
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 7, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Edith Roe, NURSE PRACTITIONERNPI 1831667468
Title
President
Phone
(208) 859-4103

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

126 Idaho Ave.
Homedale, ID 83628-8362

Mailing address

PO Box 37
Homedale, ID 83628-0037
Phone (208) 337-3898

Other names 1

  • Idaho Street Medical Clinic Doing business as

National Provider Directory

National Provider Directory

Locations

126 W Idaho Ave
Homedale, ID 83628
Phone (208) 337-7038

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1551916800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1551916800000",
    "number": "1063970143",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 37",
            "city": "HOMEDALE",
            "state": "ID",
            "postal_code": "836280037",
            "telephone_number": "208-337-3898"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "126 IDAHO AVE.",
            "city": "HOMEDALE",
            "state": "ID",
            "postal_code": "836288362",
            "telephone_number": "208-859-4103"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IDAHO STREET MEDICAL CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-03-07",
        "last_updated": "2019-03-07",
        "status": "A",
        "authorized_official_last_name": "ROE",
        "authorized_official_first_name": "EDITH",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "208-859-4103",
        "authorized_official_credential": "NURSE PRACTITIONER"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Idaho Street Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Homedale, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 7, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.