Physician Management Services of Idaho, LLC
Organization Active NPI Family Medicine Physician · Shoshone, ID
NPI 1215688346 · NPPES record last updated Jan 11, 2022
Key facts
- NPI
- 1215688346
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- Legal business name
- PHYSICIAN MANAGEMENT SERVICES OF IDAHO, LLC
- Practice address
- 113 S Apple St
Shoshone, ID 83352-5287 - Phone
- (888) 829-8550
- NPI assigned
- Jan 11, 2022
- Organization subpart
- Yes
- Parent organization (as reported)
- VAXCARE CORPORATION
Authorized official
- Name
- Brett Kenefick
- Title
- President
- Phone
- (888) 829-8550
Member of 1
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in TX
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20220909000126 | TX | Part B Supplier - Centralized Flu Biller | 6800270984 | Practice locations: Shoshone, ID |
National Provider Directory
- Part of
- Vaxcare Corporation
Locations
113 S Apple St
Shoshone, ID 83352
Phone (208) 886-2224
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | Yes |
Addresses
Primary practice location
113 S Apple St
Shoshone, ID 83352-5287
Mailing address
3113 Lawton Rd
Orlando, FL 32803-3531
Phone (888) 829-8550
Other providers in Shoshone, ID
- Lincoln County Care Center LLC
- Lincoln County EMS
- Lincoln County EMS
- Andrea Madson
- Matthew E. Kent, O.D.,P.a.
- Krista Profit
- Christopher Daniel Ritcheson
- Stephanie Roberts
- Janet Sandy
- Shoshone Rehab and Living Center
All providers in Shoshone, ID · Family Medicine Physician in Idaho
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 11, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.