1457370686 NPI number — RUSSELL FULLER MCKINLEY DDS

Table of content: RUSSELL FULLER MCKINLEY DDS (NPI 1457370686)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457370686 NPI number — RUSSELL FULLER MCKINLEY DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCKINLEY
Provider First Name:
RUSSELL
Provider Middle Name:
FULLER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

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:
1457370686
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:
2600 ROSE HILL
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-345-1386
Provider Business Mailing Address Fax Number:
208-345-2995

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2600 ROSE HILL
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-345-1386
Provider Business Practice Location Address Fax Number:
208-345-2995
Provider Enumeration Date:
07/19/2006

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: 1223G0001X , with the licence number:  D1869 , 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: 000010012469 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010012469 . This is a "CARING FOUNDATION BLUE SH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 532545 . This is a "UNITED CONCORDIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3127302 . This is a "BLUE CROSS BLUE SHIELD TN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 69450 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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