| Heritage Physician And Resource Group Llc | |
|
1009 W Quinn Rd Pocatello ID 83202-2425 | |
| (208) 238-0088 | |
| (208) 238-0055 |
| Full Name | Heritage Physician And Resource Group Llc |
|---|---|
| Speciality | General Practice |
| Location | 1009 W Quinn Rd, Pocatello, Idaho |
| Authorized Official Name and Position | Jonny Ryan Fisher (CEO) |
| Authorized Official Contact | 2082380088 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Heritage Physician And Resource Group Llc 1009 W Quinn Rd Pocatello ID 83202-2425 Ph: (208) 238-0088 | Heritage Physician And Resource Group Llc 1009 W Quinn Rd Pocatello ID 83202-2425 Ph: (208) 238-0088 |
| NPI Number | 1962896027 |
|---|---|
| Provider Enumeration Date | 03/26/2015 |
| Last Update Date | 08/15/2024 |
| Certification Date | 08/15/2024 |
| Medicare PECOS PAC ID | 0244531986 |
|---|---|
| Medicare Enrollment ID | O20151222001048 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1962896027 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1041C0700X | Social Worker - Clinical | (* (Not Available)) | Secondary |
| 208D00000X | General Practice | (* (Not Available)) | Primary |
| Provider Name | Kyle L Clifford |
|---|---|
| Provider Type | Practitioner - General Practice |
| Provider Identifiers | NPI Number: 1841285590 PECOS PAC ID: 1254405871 Enrollment ID: I20080730000858 |
| Provider Name | Gustin R Blad |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1982979936 PECOS PAC ID: 9133382708 Enrollment ID: I20120517000367 |
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