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Idaho Modern Medicine, PLLC

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Company Details

Name: Idaho Modern Medicine, PLLC
Jurisdiction: Idaho
Legal type: Limited Liability Company (D)
Status: Active-Existing
Date of registration: 07 Aug 2019 (6 years ago)
Financial Date End: 31 Aug 2025
Entity Number: 3590511
Place of Formation: IDAHO
File Number: 676176
ZIP code: 83201
County: Bannock County
Principal Address: STE E10 1000 POCATELLO CREEK RD POCATELLO, ID 83201-2953

Agent

Name Role Address
Michael Anderson Agent 7510 W POCATELLO CREEK RD, POCATELLO, ID 83201

Manager

Name Role Address Appointed On
Michael Anderson Manager 1489 PARTRIDGE CV, POCATELLO, ID 83201 2021-12-14
Katie Anderson Manager 1000 POCATELLO CREEK RD, POCATELLO, ID 83201 2020-07-21

National Provider Identifier

NPI Number:
1184255754
Certification Date:
2024-02-05

Authorized Person:

Name:
MICHAEL A ANDERSON
Role:
PHYSICIAN / OWNER
Phone:

Taxonomy:

Selected Taxonomy:
207Q00000X - Family Medicine Physician
Is Primary:
Yes

Contacts:

Fax:
2086484790

Filing

Filing Name Filing Number Filing date
Annual Report 0005848389 2024-08-06
Amendment to Certificate 0005599741 2024-02-12
Annual Report 0005336214 2023-08-01
Annual Report 0004841377 2022-08-03
Application for Reinstatement 0004528338 2021-12-14

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Date of last update: 17 May 2025

Sources: Idaho Secretary of State