Payette Lakes Medical Clinic, PA

Primary specialty

Primary Care Clinic/CenterTaxonomy code 261QP2300X

Legal business name

PAYETTE LAKES MEDICAL CLINIC, PA

Practice address

454 Rosebury Road
Suite 103
Donnelly, ID 83615

Phone

(208) 325-4455

Fax

(208) 325-4466

NPI assigned

Mar 8, 2007

Last updated

Mar 17, 2008By 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

Jacqueline R Bruns

Title

VP - Physician Services

Phone

(208) 634-4061

Specialties & licenses 1

Addresses

Other identifiers 2

Other names 1

• Donnelly Medical Clinic Other name

Tax ID family

Salmon River Medical CL2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

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

• Payette Lakes Medical Clinic, PA

  • Primary Care Clinic/Center
  • New Meadows, ID
  • NPI 1922139468
  NPD tax ID

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

{
    "created_epoch": "1173312000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1205712000000",
    "number": "1902937196",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1047",
            "city": "MCCALL",
            "state": "ID",
            "postal_code": "836381047",
            "telephone_number": "208-325-4455",
            "fax_number": "208-325-4466"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "454 ROSEBURY ROAD",
            "address_2": "SUITE 103",
            "city": "DONNELLY",
            "state": "ID",
            "postal_code": "83615",
            "telephone_number": "208-325-4455",
            "fax_number": "208-325-4466"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PAYETTE LAKES MEDICAL CLINIC, PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-08",
        "last_updated": "2008-03-17",
        "status": "A",
        "authorized_official_last_name": "BRUNS",
        "authorized_official_first_name": "JACQUELINE",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "VP - PHYSICIAN SERVICES",
        "authorized_official_telephone_number": "208-634-4061"
    },
    "taxonomies": [
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BS",
            "identifier": "000010160243",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BC",
            "identifier": "8N006",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Donnelly Medical Clinic",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

• Kelly Companies, LLC (Mountain Valley Counseling & Outdoor Therapy)
• Korena Popp FNP Medical Services LLC (The Change Clinic)
• Annalee Mangum, RN
• McCall Memorial Hospital (Donnelly Medical Clinic, a MMH Physician Clinic)
• Mountain Mobile Medicine, PLLC
• Taylor Rae, P-LCSW
• Sellers DMD PC
• Kimberly Ruth Smith, RN, BSN, CLC
• Kathryn Latham Stoll, LMFT
• Tamarack Medical Clinic

• Primary Care Clinic/Center in Donnelly, ID
• Providers in Donnelly, ID by specialty
• Primary Care Clinic/Center in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 17, 2008; 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.