1144213588 NPI number — MRS. GAYLE BONZER-FRY PT

Table of content: MRS. GAYLE BONZER-FRY PT (NPI 1144213588)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144213588 NPI number — MRS. GAYLE BONZER-FRY PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BONZER-FRY
Provider First Name:
GAYLE
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FRY
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
GAYLE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1144213588
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HORSESHOE BEND
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83629-0205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-793-3333
Provider Business Mailing Address Fax Number:
208-793-3666

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 HIGHWAY 55
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
HORSESHOE BEND
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83629-9015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-793-3333
Provider Business Practice Location Address Fax Number:
208-793-6333
Provider Enumeration Date:
08/30/2005

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: 225100000X , with the licence number:  RPT-081 , 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: 000010008652 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: T0239 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 804131800 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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