Specialized Family Medicine

Key facts

NPI

1124197702

Entity type

Organization (NPI type 2)

Primary specialty

Family Medicine Physician 207Q00000X

Legal business name

SPECIALIZED FAMILY MEDICINE

Practice address

151 N 4TH Ave
Suite B
Pocatello, ID 83201-6300

Phone

(208) 369-7147

Fax

(208) 416-6522

NPI assigned

Nov 7, 2006

Organization subpart

No

Authorized official

Name

Jordan L Bailey, MD

Title

Physician Owner

Phone

(208) 269-7147

National Provider Directory

Locations

Specialties & licenses

Addresses

Other identifiers

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Jul 21, 2022.

{
    "created_epoch": "1162857600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658361600000",
    "number": "1124197702",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "151 N 4TH AVE",
            "address_2": "SUITE B",
            "city": "POCATELLO",
            "state": "ID",
            "postal_code": "832016300",
            "telephone_number": "208-369-7147",
            "fax_number": "208-416-6522"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "151 N 4TH AVE",
            "address_2": "SUITE B",
            "city": "POCATELLO",
            "state": "ID",
            "postal_code": "832016300",
            "telephone_number": "208-369-7147",
            "fax_number": "208-416-6522"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SPECIALIZED FAMILY MEDICINE",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-07",
        "last_updated": "2022-07-21",
        "status": "A",
        "authorized_official_last_name": "BAILEY",
        "authorized_official_first_name": "JORDAN",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "PHYSICIAN OWNER",
        "authorized_official_telephone_number": "208-269-7147",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": "ID",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS",
            "identifier": "8F991",
            "state": "ID"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "806364600",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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