1447311139 NPI number — BEAR LAKE COUNTY

Table of content: THOMAS B PHAM PHARM. D. (NPI 1952600942)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447311139 NPI number — BEAR LAKE COUNTY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEAR LAKE COUNTY
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:
BEAR LAKE COUNTY AMBULANCE SERVICE
Provider Other Organization Name Type Code:
3
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:
1447311139
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 248
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTPELIER
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83254
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-847-2274
Provider Business Mailing Address Fax Number:
208-847-1189

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
385 CEMETARY ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTPELIER
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83254
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-847-2247
Provider Business Practice Location Address Fax Number:
208-847-1189
Provider Enumeration Date:
12/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HADDOCK
Authorized Official First Name:
KERRY
Authorized Official Middle Name:
Authorized Official Title or Position:
COUNTY CLERK
Authorized Official Telephone Number:
208-945-2212

Provider Taxonomy Codes

  • Taxonomy code: 341600000X , with the licence number:  7602 , 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: E0062 . This is a "BLUE CROSS OF IDAHO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000010014272 . This is a "BLUE SHIELD OF IDAHO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 002807400 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 109956600 . This is a "MEDICAID" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




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