1134342264 NPI number — DEER POINT FAMILY PRACTICE PC

Table of content: (NPI 1134342264)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134342264 NPI number — DEER POINT FAMILY PRACTICE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEER POINT FAMILY PRACTICE PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134342264
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4979
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:
83711-4979
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-322-7284
Provider Business Mailing Address Fax Number:
208-323-9070

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6023 N EAGLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83713-0997
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-322-7284
Provider Business Practice Location Address Fax Number:
208-323-9070
Provider Enumeration Date:
04/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TUBBS
Authorized Official First Name:
GARY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
208-322-7284

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 002643400 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000010028455 . This is a "REGENCE BLUE SHIELD OF ID" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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