1477671477 NPI number — POCATELLO CLINIC OF INTERNAL MEDICINE PA

Table of content: (NPI 1477671477)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477671477 NPI number — POCATELLO CLINIC OF INTERNAL MEDICINE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POCATELLO CLINIC OF INTERNAL MEDICINE PA
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:
1477671477
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:
PO BOX 880
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:
83204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-233-4562
Provider Business Mailing Address Fax Number:
208-234-4638

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
707 N 7TH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-233-4562
Provider Business Practice Location Address Fax Number:
208-234-4638
Provider Enumeration Date:
03/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BENSON
Authorized Official First Name:
MARK
Authorized Official Middle Name:
P
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
208-233-4562

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 29296 . This is a "GROUP BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: CP9190 . This is a "GROUP RAILROAD MEDICARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 88765 . This is a "GROUP BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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