1710053756 NPI number — EAGLE ROCK REGIONAL NEUROLOGY, P.C.

Table of content: (NPI 1710053756)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710053756 NPI number — EAGLE ROCK REGIONAL NEUROLOGY, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAGLE ROCK REGIONAL NEUROLOGY, P.C.
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:
1710053756
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:
1995 E 17TH ST
Provider Second Line Business Mailing Address:
STE 5
Provider Business Mailing Address City Name:
IDAHO FALLS
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83404-6493
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-552-5700
Provider Business Mailing Address Fax Number:
208-552-5703

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1995 E 17TH ST
Provider Second Line Business Practice Location Address:
STE 5
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404-6493
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-552-5700
Provider Business Practice Location Address Fax Number:
208-552-5703
Provider Enumeration Date:
11/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DOMARAD
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
KARL
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
208-552-5700

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  O343 , 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: S5247 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com