Organization
GEM STATE DERMATOLOGY, PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. MICHELLE MORGAN (PRACTICE MANAGER)
(208) 424-9101
Entity
Organization
Contact information
Practice address
388 E. PARKCENTER BLVD., BOISE, ID 83706
(208) 424-9101
(208) 424-5072
Mailing address
PO BOX 1603, BOISE, ID 83702-1603
(208) 424-9101
(208) 424-5072
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
M7247
ID
261QM2500X
Medical Specialty Clinic/Center
M7247
ID
363A00000X
Physician Assistant
PA377
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
805054600
—
ID
Enumeration date
02/15/2007
Last updated
12/02/2014
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