NPIMap

Organization Active NPI

Idaho State University

Doing business as Idaho State Sports Medicine

  • Family Medicine Physician
  • Pocatello, ID
National Provider Identifier
1801292115
Registry record updated Nov 13, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
IDAHO STATE UNIVERSITY
Doing business as
Idaho State Sports Medicine
Practice address
921 S 8TH Ave Stop 8173
Sports and Orthopaedic Center
Pocatello, ID 83209-8173
Phone
(208) 282-3408
NPI assigned
Nov 13, 2014
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 13, 2014

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

Authorized official

Name
Jodi Wotowey
Title
Head Athletic Trainer
Phone
(208) 282-3408

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207Q00000X Primary
Sports Medicine (Family Medicine) PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207QS0010X
Orthopaedic Surgery PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207X00000X
Sports Medicine (Orthopaedic Surgery) PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207XX0005X

Addresses

Primary practice location

921 S 8TH Ave Stop 8173
Sports and Orthopaedic Center
Pocatello, ID 83209-8173

Mailing address

5050 Spring Valley Rd
Dallas, TX 75244-3995
Phone (800) 555-9073

Other names 1

  • Idaho State Sports Medicine Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Idaho State University22 organizations share this tax ID, including this one

Other organizations with this tax ID 21

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

View all 21

Locations

921 S 8th Ave
Stop 8173
Pocatello, ID 83209
Phone (208) 282-3408

Practitioners & affiliated clinicians

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.

NPI Registry JSON

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

{
    "created_epoch": "1415836800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1415836800000",
    "number": "1801292115",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5050 SPRING VALLEY RD",
            "city": "DALLAS",
            "state": "TX",
            "postal_code": "752443995",
            "telephone_number": "800-555-9073",
            "fax_number": "972-367-3452"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "921 S 8TH AVE STOP 8173",
            "address_2": "SPORTS AND ORTHOPAEDIC CENTER",
            "city": "POCATELLO",
            "state": "ID",
            "postal_code": "832098173",
            "telephone_number": "208-282-3408"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IDAHO STATE UNIVERSITY",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-11-13",
        "last_updated": "2014-11-13",
        "status": "A",
        "authorized_official_last_name": "WOTOWEY",
        "authorized_official_first_name": "JODI",
        "authorized_official_title_or_position": "HEAD ATHLETIC TRAINER",
        "authorized_official_telephone_number": "208-282-3408"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207QS0010X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Family Medicine, Sports Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207X00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Orthopaedic Surgery",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207XX0005X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Orthopaedic Surgery, Sports Medicine",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Idaho State Sports Medicine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Pocatello, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 13, 2014; 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.