Individual
PHILIP JON VAN DE GRIEND
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
465 MEMORIAL DR, POCATELLO, ID 83201-4008
(208) 232-7862
Mailing address
465 MEMORIAL DR, POCATELLO, ID 83201-4008
(208) 234-4700
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
2014-01351
NC
207Q00000X
Family Medicine Physician
LL33736
SC
207Q00000X
Family Medicine Physician
Primary
M-15982
ID
207Q00000X
Family Medicine Physician
MD-42445
IA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1275829376
—
NC
05
—
NC2135
—
SC
Enumeration date
06/27/2011
Last updated
09/30/2021
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