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2100 University Dr Ste 107 Boise ID 83725-0001 | |
| (208) 426-1523 | |
| (208) 426-2302 |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 2100 University Dr Ste 107, Boise, Idaho |
| Authorized Official Name and Position | Stephanie Hudon (CLINICAL PROGRAM DIRECTOR) |
| Authorized Official Contact | 2089953765 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
1910 University Dr # Ms 1855 Boise ID 83725 Ph: (208) 426-1523 | 2100 University Dr Ste 107 Boise ID 83725-0001 Ph: (208) 426-1523 |
| NPI Number | 1134905243 |
|---|---|
| Provider Enumeration Date | 09/05/2023 |
| Last Update Date | 08/29/2024 |
| Medicare PECOS PAC ID | 5991112468 |
|---|---|
| Medicare Enrollment ID | O20240829003019 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1134905243 | NPI | - | NPPES |
| 1134905243 | Medicaid | ID |
| Provider Name | Richard G Radnovich |
|---|---|
| Provider Type | Practitioner - Sports Medicine |
| Provider Identifiers | NPI Number: 1407944655 PECOS PAC ID: 9537063672 Enrollment ID: I20040805001416 |
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