1518977826 NPI number — BRYAN G HART PA

Table of content: BRYAN G HART PA (NPI 1518977826)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518977826 NPI number — BRYAN G HART PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HART
Provider First Name:
BRYAN
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
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:
1518977826
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3340 E GOLDSTONE WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83642-1026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-367-5170
Provider Business Mailing Address Fax Number:
208-367-5180

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1072 N LIBERTY ST
Provider Second Line Business Practice Location Address:
SUITE 303
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83704-2800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-367-4035
Provider Business Practice Location Address Fax Number:
208-367-7111
Provider Enumeration Date:
08/09/2006

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: 363A00000X , with the licence number:  PA397 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA-397 , 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: PAWF2 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 134024 . This is a "OMAP" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 000010139458 . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8J703 . This is a "BLUE CROSS OF IDAHO GROUP" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8J190 . This is a "BLUE CROSS OF IDAHO GROUP" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 0209674 . This is a "WA DEPARTMENT OF LABOR" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: PAOV4 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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