Organization
GEM STATE PEDIATRICS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MARIO BRUS MD (OWNER)
(208) 706-5460
Entity
Organization
Contact information
Practice address
520 S EAGLE RD, SUITE 1209, MERIDIAN, ID 83642-6308
(208) 706-5460
(208) 706-5465
Mailing address
520 S EAGLE RD, SUITE 1209, MERIDIAN, ID 83642-6308
(208) 706-5460
(208) 706-5465
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
M5562
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010001341
BLUE SHIELD OF IDAHO
ID
01
—
57885
BLUE CROSS OF IDAHO
ID
Enumeration date
01/08/2007
Last updated
08/22/2020
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