# IDAHO STATE UNIVERSITY

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Idaho State Sports Medicine
- **Organization subpart:** No

## Provider details

- **NPI number:** 1801292115
- **Authorized official:** JODI WOTOWEY (HEAD ATHLETIC TRAINER)
- **Authorized official phone:** (208) 282-3408

## Contact information

- **Practice address:** 921 S 8TH AVE STOP 8173, SPORTS AND ORTHOPAEDIC CENTER, POCATELLO, ID 83209-8173
- **Practice address phone:** (208) 282-3408
- **Mailing address:** 5050 SPRING VALLEY RD, DALLAS, TX 75244-3995
- **Mailing address phone:** (800) 555-9073
- **Mailing address fax:** (972) 367-3452

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |
| 207QS0010X | Sports Medicine (Family Medicine) Physician | — | NULL | — |
| 207QS0010X | Sports Medicine (Family Medicine) Physician | — | — | — |
| 207X00000X | Orthopaedic Surgery Physician | — | NULL | — |
| 207X00000X | Orthopaedic Surgery Physician | — | — | — |
| 207XX0005X | Sports Medicine (Orthopaedic Surgery) Physician | — | NULL | — |
| 207XX0005X | Sports Medicine (Orthopaedic Surgery) Physician | — | — | — |

## Other

- **Enumeration date:** 11/13/2014
- **Last updated:** 11/13/2014