1770963274 NPI number — ELEVATE HEALTH GROUP PLLC

Table of content: (NPI 1770963274)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770963274 NPI number — ELEVATE HEALTH GROUP PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELEVATE HEALTH GROUP PLLC
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:
KEYSTONE PHYSICAL MEDICINE
Provider Other Organization Name Type Code:
3
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:
1770963274
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2193
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83701-2193
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
420 W MAIN ST
Provider Second Line Business Practice Location Address:
#206
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83702-7284
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-426-9200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/01/2015

Additional Information

Authorized Official

Authorized Official Last Name:
SARTIN
Authorized Official First Name:
CORY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CLINIC DIRECTOR
Authorized Official Telephone Number:
208-426-9200

Provider Taxonomy Codes

  • Taxonomy code: 2081P2900X , with the licence number:  NP-1093A , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208VP0000X , with the licence number: NP-1093A , 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)





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