1578741393 NPI number — BOISE VALLEY DOCTORS, P.A.

Table of content: (NPI 1578741393)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578741393 NPI number — BOISE VALLEY DOCTORS, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOISE VALLEY DOCTORS, P.A.
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:
FIRSTLINE MEDICAL
Provider Other Organization Name Type Code:
3
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:
1578741393
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7667
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:
83707-1667
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-323-7588
Provider Business Mailing Address Fax Number:
208-515-3468

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6000 W OVERLAND 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:
83709-3013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-323-7588
Provider Business Practice Location Address Fax Number:
208-515-3468
Provider Enumeration Date:
02/04/2008

Additional Information

Authorized Official

Authorized Official Last Name:
NEUENSCHWANDER
Authorized Official First Name:
ALLEN
Authorized Official Middle Name:
ROGER
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
208-323-7588

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  M-2852 , 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: M-2852 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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