Provider Demographics
NPI:1740524701
Name:FUNCTIONAL AND INTEGRATIVE MEDICINE OF IDAHO PA
Entity type:Organization
Organization Name:FUNCTIONAL AND INTEGRATIVE MEDICINE OF IDAHO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:M
Authorized Official - Last Name:EBERHARTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-863-1399
Mailing Address - Street 1:2905 W JORDAN ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-2134
Mailing Address - Country:US
Mailing Address - Phone:208-863-1399
Mailing Address - Fax:
Practice Address - Street 1:3858 N GARDEN CENTER WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-5008
Practice Address - Country:US
Practice Address - Phone:208-385-7711
Practice Address - Fax:208-385-0346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4631207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDB63788Medicare UPIN
ID1118207Medicare PIN