1093717787 NPI number — DR. RICHARD MICHAEL ALLEN DPM

Table of content: DR. RICHARD MICHAEL ALLEN DPM (NPI 1093717787)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093717787 NPI number — DR. RICHARD MICHAEL ALLEN DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALLEN
Provider First Name:
RICHARD
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1093717787
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/07/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1630 23RD AVE
Provider Second Line Business Mailing Address:
SUITE 1001
Provider Business Mailing Address City Name:
LEWISTON
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83501-6350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-743-3688
Provider Business Mailing Address Fax Number:
208-743-5162

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1630 23RD AVE
Provider Second Line Business Practice Location Address:
SUITE 1001
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-6350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-743-3688
Provider Business Practice Location Address Fax Number:
208-743-5162
Provider Enumeration Date:
08/11/2005

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: 213ES0103X , with the licence number:  P-143 , 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: 0027887 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000010015686 . This is a "REGENCE BLUESHIELD OF ID" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: P9186 . 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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