1356306740 NPI number — MRS. KIMBERLY D FERGUISON MD-PEDIATRICS

Table of content: MRS. KIMBERLY D FERGUISON MD-PEDIATRICS (NPI 1356306740)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356306740 NPI number — MRS. KIMBERLY D FERGUISON MD-PEDIATRICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FERGUISON
Provider First Name:
KIMBERLY
Provider Middle Name:
D
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MD-PEDIATRICS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRANWEHR
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1356306740
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/20/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 191050
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:
83719-1050
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-955-6500
Provider Business Mailing Address Fax Number:
208-955-6501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3280 E LANARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-5982
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-377-4400
Provider Business Practice Location Address Fax Number:
208-377-4416
Provider Enumeration Date:
04/19/2006

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: 208000000X , with the licence number:  M9507 , 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: 76552 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010154462 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 807392600 . This is a "HEALTHY CONNECTIONS MCAID" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 807354800 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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