Individual
MARK E KIECKBUSCH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
190 E BANNOCK ST, BOISE, ID 83712-6241
(208) 381-2367
(208) 381-4762
Mailing address
PO BOX 9589, BOISE, ID 83707-4589
(208) 472-8104
(208) 344-1926
Taxonomy
Speciality
Code
Description
License number
State
207ZH0000X
Hematology (Pathology) Physician
M6070
ID
207ZP0102X
Anatomic Pathology & Clinical Pathology Physician
Primary
M6070
ID
Other
Enumeration date
05/20/2006
Last updated
12/11/2007
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