Organization
STAR MEDICAL CENTER PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ELMER G DODGE JR. RNP (PRESIDENT OWNER)
(208) 286-0666
Entity
Organization
Contact information
Practice address
9858 W STATE ST, STAR, ID 83669-5210
(208) 286-0666
(208) 286-0565
Mailing address
PO BOX 44267, BOISE, ID 83711-0267
(208) 286-0666
(208) 286-0565
Taxonomy
Speciality
Code
Description
License number
State
163WG0000X
General Practice Registered Nurse
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
807071100
—
ID
01
—
8L030
BLUE CROSS OF ID
ID
Enumeration date
01/16/2007
Last updated
05/14/2013
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