1649563347 NPI number — P. ROMAN BURK DPM PC

Table of content: (NPI 1649563347)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649563347 NPI number — P. ROMAN BURK DPM PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
P. ROMAN BURK DPM 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:
ROCKY MOUNTAINT FOOT & ANKLE
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:
1649563347
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2022
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:
#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:
208-855-5955
Provider Business Mailing Address Fax Number:
208-459-8628

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2667 E GALA CT STE 130
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-2788
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-795-5090
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/27/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BURK
Authorized Official First Name:
P ROMAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
208-855-5955

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  P197 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X , with the licence number: P197 , 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: 808001900 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000000154263 . This is a "REGENCE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: P9383 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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