1306064258 NPI number — P. ROMAN BURK D.P.M.

Table of content: P. ROMAN BURK D.P.M. (NPI 1306064258)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306064258 NPI number — P. ROMAN BURK D.P.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURK
Provider First Name:
P.
Provider Middle Name:
ROMAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.P.M.
Provider Gender Code:
M

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:
1306064258
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1818 S 10TH AVE
Provider Second Line Business Mailing Address:
SUITE 250
Provider Business Mailing Address City Name:
CALDWELL
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83605-4803
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-459-0891
Provider Business Mailing Address Fax Number:
208-459-8628

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1818 S 10TH AVE
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
CALDWELL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83605-4803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-459-0891
Provider Business Practice Location Address Fax Number:
208-459-8628
Provider Enumeration Date:
04/23/2007

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: 213E00000X , with the licence number:  41000197 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X , with the licence number: P-197 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000010167550 . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: P2447 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8080019 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6701670001 . This is a "MEDICARE DME PTAN" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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