1386758464 NPI number — SARAH JO GRAHAM MPT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386758464 NPI number — SARAH JO GRAHAM MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAHAM
Provider First Name:
SARAH
Provider Middle Name:
JO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LUGINBILL
Provider Other First Name:
SARAH
Provider Other Middle Name:
JO
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:
1386758464
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
278 S NESKOWIN WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAGLE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83616-4964
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-939-8176
Provider Business Mailing Address Fax Number:
208-939-3338

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
457 S FITNESS PL
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
EAGLE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83616-6568
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-939-3332
Provider Business Practice Location Address Fax Number:
208-939-3338
Provider Enumeration Date:
08/18/2006

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: 225100000X , with the licence number:  RPT-1804 , 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: 000010144132 . This is a "HEALTHSENSE 65/ MED ADVAN" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 11347662 . This is a "FIRST HEALTH NETWORK" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: T7697 . This is a "TRUE BLUE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: T7697 . This is a "HMO BLUE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010144132 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 806671700 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: T7697 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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