Organization
MEDICAL CENTER FOR CHILDREN & ADOLESCENTS, PA
Active
Other names
The Pediatric Center
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MICHAEL JUDE PANKAU M.D. (PRESIDENT)
(208) 523-3060
Entity
Organization
Contact information
Practice address
3430 WASHINGTON PKWY, IDAHO FALLS, ID 83404-7579
(208) 523-3060
Mailing address
3430 WASHINGTON PKWY, IDAHO FALLS, ID 83404-7579
(208) 523-3060
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010006561
BLUE SHIELD
ID
01
—
85456
BLUE CROSS
ID
Enumeration date
07/29/2006
Last updated
08/22/2020
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