Organization
IDAHO ALLERGY & ASTHMA CLINIC PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. WENDELL E PETTY M.D. (PRESIDENT)
(208) 529-9292
Entity
Organization
Contact information
Practice address
3422 S 15TH E, IDAHO FALLS, ID 83404-8262
(208) 529-9292
(208) 523-2397
Mailing address
3422 S 15TH E, IDAHO FALLS, ID 83404-8262
(208) 529-9292
(208) 523-2397
Taxonomy
Speciality
Code
Description
License number
State
207K00000X
Allergy & Immunology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0000100004631
BLUE SHIELD
ID
05
—
002516900
—
ID
01
—
8N147
BLUE CROSS
ID
01
—
DG4709
RAILROAD MEDICARE
ID
Enumeration date
03/14/2007
Last updated
06/21/2019
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