Organization
TONY C ROISUM MD PA
Active
Other names
Idaho Falls Family & Sports Medicine
Organization subpart
No
Provider details
NPI number
Authorized official
JACQUELINE KELSEY (OFFICE MANAGER)
(208) 524-3416
Entity
Organization
Contact information
Practice address
3360 WASHINGTON PKWY, SUITE 1, IDAHO FALLS, ID 83404-8333
(208) 524-3416
(208) 524-3138
Mailing address
3360 WASHINGTON PKWY STE 1, IDAHO FALLS, ID 83404-7592
(208) 524-3416
(208) 524-3138
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
M7389
ID
207QS0010X
Sports Medicine (Family Medicine) Physician
M7389
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010004286
BLUE SHIELD
ID
05
—
119166700
—
WY
01
—
185461600
US DEPT OF LABOR
ID
01
—
23397
BLUE SHIELD
—
05
—
502862456001
—
UT
05
—
805076700
—
ID
01
—
B5824
BLUE CROSS
—
01
—
DJ475
BLUE CROSS
ID
Enumeration date
10/05/2006
Last updated
01/16/2026
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