PAYETTE LAKES MEDICAL CLINIC PA NPI 1902937196

NPI Information

NPI: 1902937196
Provider Name: PAYETTE LAKES MEDICAL CLINIC, PA
Classification: Clinic/Center - 261QP2300X
Specialization: Primary Care
Entity Type: Organization
Other Name: DONNELLY MEDICAL CLINIC
Address: 454 ROSEBURY ROAD
SUITE 103
DONNELLY, ID
ZIP 83615
Phone: (208) 325-4455

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NPI Details

PAYETTE LAKES MEDICAL CLINIC, PA is a primary care clinic center in Donnelly, ID. PAYETTE LAKES MEDICAL CLINIC, PA NPI is 1902937196. The provider is registered as an organization entity type.
The provider Other Name Is Donnelly Medical Clinic.

The provider's business location address is:

454 ROSEBURY ROAD
SUITE 103
DONNELLY, ID
ZIP 83615
Phone: (208) 325-4455
Fax: (208) 325-4466

The provider's authorized official is Jacqueline R Bruns .
The authorized official title is Vp - Physician Services and has the following contact phone number (208) 634-4061.

The enumeration date for this NPI number is 3/8/2007 and was last updated on 3/17/2008.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No.	Taxonomy Code	Taxonomy Clasification	Taxonomy Specialization	License Number	License State	Primary
1	261QP2300X	Clinic/Center	Primary Care			Yes

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

No.	Other Provider Identifier	Other Provider Identifier Type	Other Provider Identifier State	Other Provider Identifier Issuer
1	8N006	OTHER	IDAHO	BC
2	1372681	MEDICARE PIN	IDAHO
3	000010160243	OTHER	IDAHO	BS

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 11/21/2025

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