Individual
JORDAN LYLE BAILEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
151 N 4TH AVE, SUITE B, POCATELLO, ID 83201-6300
(208) 269-7147
(208) 416-6522
Mailing address
151 N 4TH AVE, SUITE B, POCATELLO, ID 83201-6300
(208) 269-7147
(208) 416-6522
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
M9245
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
76704
BLUE CROSS
ID
05
—
807222600
—
ID
Enumeration date
10/04/2006
Last updated
08/10/2021
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