Organization
MOUNTAIN STATES MEDICAL GROUP PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
RICHARD MCCHRYSTAL PA (PRESIDENT)
(208) 378-2840
Entity
Organization
Contact information
Practice address
4809 FAIRVIEW AVENUE, BOISE, ID 83706-2242
(208) 378-2840
(208) 323-9070
Mailing address
PO BOX 4236, BOISE, ID 83711-4236
(208) 378-2840
(208) 323-9070
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010017966
RBSI
ID
01
—
8C196
BLUE CROSS
ID
Enumeration date
10/01/2006
Last updated
09/15/2008
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