1083809727 NPI number — MICHAEL R DIBENEDETTO MD PLLC

Table of content: (NPI 1083809727)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083809727 NPI number — MICHAEL R DIBENEDETTO MD PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL R DIBENEDETTO MD PLLC
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:
6
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:
1083809727
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30544 HWY 200
Provider Second Line Business Mailing Address:
STE 102
Provider Business Mailing Address City Name:
PONDERAY
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83852
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-265-9817
Provider Business Mailing Address Fax Number:
208-263-7249

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30544 HWY 200
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
PONDERAY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-265-9836
Provider Business Practice Location Address Fax Number:
208-263-7249
Provider Enumeration Date:
09/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GARMAN
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
208-265-9817

Provider Taxonomy Codes

  • Taxonomy code: 261QR0404X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DG3627 . This is a "PALMETTO GBA RAILROAD MED" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 806452000 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000010140056 . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8N259 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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