1275664583 NPI number — IDAHO DEPT OF HEALTH & WELFARE REG 6 AMH PSR PRES

Table of content: (NPI 1275664583)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275664583 NPI number — IDAHO DEPT OF HEALTH & WELFARE REG 6 AMH PSR PRES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IDAHO DEPT OF HEALTH & WELFARE REG 6 AMH PSR PRES
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:
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:
1275664583
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
421 MEMORIAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POCATELLO
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83201-4008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-234-7900
Provider Business Mailing Address Fax Number:
208-236-6328

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
223 N STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRESTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83263-1140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-852-0634
Provider Business Practice Location Address Fax Number:
208-852-2136
Provider Enumeration Date:
03/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
AXFORD
Authorized Official First Name:
ED
Authorized Official Middle Name:
Authorized Official Title or Position:
PROGRAM MANAGER
Authorized Official Telephone Number:
208-234-7900

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: HW108 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010019235 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8073684 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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