Provider Demographics
NPI:1447629555
Name:PETRIE WHITE FAMILY MEDICINE OF IDAHO
Entity type:Organization
Organization Name:PETRIE WHITE FAMILY MEDICINE OF IDAHO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:208-365-7131
Mailing Address - Street 1:2001 E QUAIL RUN RD
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-5059
Mailing Address - Country:US
Mailing Address - Phone:208-365-7131
Mailing Address - Fax:208-365-4464
Practice Address - Street 1:2001 E QUAIL RUN RD
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-5059
Practice Address - Country:US
Practice Address - Phone:208-365-7131
Practice Address - Fax:208-365-4464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-18
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7802207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805196400Medicaid
ID805196400Medicaid
IDH36248Medicare UPIN