1598789950 NPI number — IDAHO NEPHROLOGY ASSOCIATES, L.L.C

Table of content: (NPI 1598789950)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598789950 NPI number — IDAHO NEPHROLOGY ASSOCIATES, L.L.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IDAHO NEPHROLOGY ASSOCIATES, L.L.C
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:
1598789950
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5610 GAGE ST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83706-1349
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-367-3370
Provider Business Mailing Address Fax Number:
208-367-3003

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5610 GAGE ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83706-1349
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-367-3370
Provider Business Practice Location Address Fax Number:
208-367-3003
Provider Enumeration Date:
07/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ADCOX
Authorized Official First Name:
MICHEAL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
208-367-3370

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CD6921 . This is a "RR MEDICARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010006436 . This is a "BLUE SHIELD OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8A133 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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