1487688990 NPI number — BRENT CHRISTENSEN DPM

Table of content: BRENT CHRISTENSEN DPM (NPI 1487688990)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487688990 NPI number — BRENT CHRISTENSEN DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHRISTENSEN
Provider First Name:
BRENT
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1487688990
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1777 E CLARK ST
Provider Second Line Business Mailing Address:
SUITE 220
Provider Business Mailing Address City Name:
POCATELLO
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83201-3357
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-235-1777
Provider Business Mailing Address Fax Number:
208-232-7518

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1777 E CLARK ST
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-3357
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-235-1777
Provider Business Practice Location Address Fax Number:
208-232-7518
Provider Enumeration Date:
07/10/2006

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: 213E00000X , with the licence number:  P-166 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213ES0103X , with the licence number: P-166 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 000010152768 . This is a "BLUE SHEILD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 806402300 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: P-1985 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 71-0943024 . This is a "FEIN" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: P00031188 . This is a "MEDICARE RAIL ROAD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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