1003852849 NPI number — MRS. CORTNEY A VANDENBURGH DO

Table of content: MRS. CORTNEY A VANDENBURGH DO (NPI 1003852849)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003852849 NPI number — MRS. CORTNEY A VANDENBURGH DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANDENBURGH
Provider First Name:
CORTNEY
Provider Middle Name:
A
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GILBERTSON
Provider Other First Name:
CORTNEY
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1003852849
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
190 E BANNOCK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83712-6241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-381-2222
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1450 AVIATION DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
HAILEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83333-8785
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-788-3434
Provider Business Practice Location Address Fax Number:
208-788-2025
Provider Enumeration Date:
06/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  O0419 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: MR0827 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 807191900 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00721168 . This is a "MCRR" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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