1730101148 NPI number — TIMOTHY J JOHANS MD

Table of content: TIMOTHY J JOHANS MD (NPI 1730101148)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730101148 NPI number — TIMOTHY J JOHANS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHANS
Provider First Name:
TIMOTHY
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1730101148
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6140 W CURTISIAN AVE STE 400
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:
83704-8907
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-327-5600
Provider Business Mailing Address Fax Number:
208-327-5602

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6140 CURTISIAN AVE
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83704-8880
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-327-5600
Provider Business Practice Location Address Fax Number:
208-327-5602
Provider Enumeration Date:
07/24/2006

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: 207T00000X , with the licence number:  M6183 , 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: 194498 . This is a "OMAP" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 72371 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 1730101148 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100000076910 . This is a "REGENCE BLUESHIELD OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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