# IDAHO MODERN MEDICINE - PLLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1184255754
- **Authorized official:** MICHAEL A ANDERSON DO (PHYSICIAN / OWNER)
- **Authorized official phone:** (208) 648-4789

## Contact information

- **Practice address:** 1000 POCATELLO CREEK RD STE E10, POCATELLO, ID 83201-2953
- **Practice address phone:** (208) 317-5371
- **Mailing address:** 1000 POCATELLO CREEK RD STE E10, POCATELLO, ID 83201-2953
- **Mailing address phone:** (208) 648-4789
- **Mailing address fax:** (208) 648-4790

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 01/31/2020
- **Last updated:** 02/05/2024