# DERMATOLOGY OF EASTERN IDAHO PA

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

## Provider details

- **NPI number:** 1548259161
- **Authorized official:** KAY BISHOP M.D. (OWNER)
- **Authorized official phone:** (208) 745-0200

## Contact information

- **Practice address:** 703 RIGBY LAKE DR, RIGBY, ID 83442-5192
- **Practice address phone:** (208) 745-0200
- **Practice address fax:** (208) 745-0212
- **Mailing address:** 703 RIGBY LAKE DR, RIGBY, ID 83442-5192
- **Mailing address phone:** (208) 745-0200
- **Mailing address fax:** (208) 745-0212

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 174400000X | Specialist | M-6569 | ID | Yes |

## Other

- **Enumeration date:** 10/17/2005
- **Last updated:** 06/30/2010

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 806512200 | — | ID |