Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207X00000X | Orthopaedic Surgeon | M-12085 | ID |
N | 207XX0005X | Sports Medicine Orthopaedic Surgeon | M-12085 | ID |
NPI | 1104928670 |
---|---|
Provider Name | Gregory M Ford |
First Address | Pocatello, ID 83201-2762 |
Second Address | Pocatello, ID 83201-2762 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/09/2006 |
Last Update Date | 05/05/2017 |