Integrated Dermatology of Idaho LLC

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

Legal business name

INTEGRATED DERMATOLOGY OF IDAHO LLC

Doing business as

GEM State Dermatology

Practice address

388 E Parkcenter Blvd
Boise, ID 83706-3942

Phone

(208) 424-9101

Fax

(208) 424-5072

NPI assigned

Aug 7, 2018

Last updated

Aug 7, 2018By 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

Jeffrey Queen

Title

Owner

Phone

(561) 314-2000

Specialties & licenses 1

Addresses

Other names 1

• GEM State Dermatology Doing business as

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

{
    "created_epoch": "1533600000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1533600000000",
    "number": "1508345091",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4700 EXCHANGE CT STE 110",
            "city": "BOCA RATON",
            "state": "FL",
            "postal_code": "334314450",
            "telephone_number": "561-314-2000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "388 E PARKCENTER BLVD",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837063942",
            "telephone_number": "208-424-9101",
            "fax_number": "208-424-5072"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INTEGRATED DERMATOLOGY OF IDAHO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-08-07",
        "last_updated": "2018-08-07",
        "status": "A",
        "authorized_official_last_name": "QUEEN",
        "authorized_official_first_name": "JEFFREY",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "561-314-2000"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "GEM State Dermatology",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Dermatology Physician in Boise, ID
• Providers in Boise, ID by specialty
• Dermatology Physician in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 7, 2018; 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.