Provider Demographics
NPI:1881144780
Name:MERIDIAN PHYSICAL MEDICINE
Entity type:Organization
Organization Name:MERIDIAN PHYSICAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAKAYLA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUNYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-887-6810
Mailing Address - Street 1:2016 S EAGLE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6707
Mailing Address - Country:US
Mailing Address - Phone:208-887-6810
Mailing Address - Fax:208-887-6797
Practice Address - Street 1:2016 S EAGLE RD
Practice Address - Street 2:SUITE B
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6707
Practice Address - Country:US
Practice Address - Phone:208-887-6810
Practice Address - Fax:208-887-6797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1345A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1790053338OtherNPI