Boise State University

Primary specialty

Community Health Clinic/CenterTaxonomy code 261QC1500X

Legal business name

BOISE STATE UNIVERSITY

Doing business as

Boise State University Public Health Clinic

Practice address

2100 University Dr Ste 107
Boise, ID 83725-0001

Phone

(208) 426-1523

Fax

(208) 426-2302

NPI assigned

Sep 5, 2023

Last updated

Aug 29, 2024By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Dr. Stephanie Hudon, PHD

Title

Clinical Program Director

Phone

(208) 995-3765

Specialties & licenses 4

Addresses

Other identifiers 1

Other names 1

• Boise State University Public Health Clinic Doing business as

Medicare fee-for-service enrollment

Enrolled in ID

Enrollment records 1

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

• Boise State University

  • Clinical Medical Laboratory
  • Boise, ID
  • NPI 1770183089

  5991112468

  Same PAC ID

Tax ID family

Boise State University3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

• Boise State Health Center

  dba Boise State University

  • Student Health Clinic/Center
  • Boise, ID
  • NPI 1194865444
  NPD tax ID
• Boise State University

  • Clinical Medical Laboratory
  • Boise, ID
  • NPI 1770183089
  NPD tax ID

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Richard Radnovich, DO

  • Sports Medicine (Family Medicine) Physician
  • Boise, ID
  • NPI 1407944655
  Medicare reassignment NPD

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

{
    "created_epoch": "1693872000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1724889600000",
    "number": "1134905243",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1910 UNIVERSITY DR",
            "address_2": "# MS 1855",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "83725",
            "telephone_number": "208-426-1523",
            "fax_number": "208-426-2302"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2100 UNIVERSITY DR STE 107",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837250001",
            "telephone_number": "208-426-1523",
            "fax_number": "208-426-2302"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BOISE STATE UNIVERSITY",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-09-05",
        "last_updated": "2024-08-29",
        "certification_date": "2024-08-29",
        "status": "A",
        "authorized_official_last_name": "HUDON",
        "authorized_official_first_name": "STEPHANIE",
        "authorized_official_title_or_position": "CLINICAL PROGRAM DIRECTOR",
        "authorized_official_telephone_number": "208-995-3765",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "PHD"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "2083P0901X",
            "taxonomy_group": "",
            "desc": "Preventive Medicine, Public Health & General Preventive Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "251K00000X",
            "taxonomy_group": "",
            "desc": "Public Health or Welfare",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QC1500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Community Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1134905243",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Boise State University Public Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Boise State University Public Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Boise Speech and Hearing Clinic
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• Boise Spine Surgery P.a.
• Boise Sports Chiropractic Clinic
• Boise State Health Center (Boise State University)
• Boise State University
• Boise Therapeutic Massage Center, LLC
• Boise Toothtown Dentistry for Kids PLLC
• Boise Towne Square Dental
• Boise Towne Square Dental

• Community Health Clinic/Center in Boise, ID
• Providers in Boise, ID by specialty
• Community Health Clinic/Center in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 29, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.