Provider Demographics
NPI:1871952267
Name:SNAKE RIVER PEDIATRICS, PC
Entity type:Organization
Organization Name:SNAKE RIVER PEDIATRICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BERRIA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, PA-C
Authorized Official - Phone:208-740-4518
Mailing Address - Street 1:1100 NW 12TH ST
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-5040
Mailing Address - Country:US
Mailing Address - Phone:208-452-6556
Mailing Address - Fax:541-216-6557
Practice Address - Street 1:1100 NW 12TH ST
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-5040
Practice Address - Country:US
Practice Address - Phone:208-452-6556
Practice Address - Fax:541-216-6557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-15
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR208000000X, 363A00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty