1811906076 NPI number — RONALD E JUTZY MD INC

Table of content: (NPI 1811906076)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811906076 NPI number — RONALD E JUTZY MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RONALD E JUTZY MD INC
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:
1811906076
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6140 CURTISIAN AVE
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83704-8880
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-367-3500
Provider Business Mailing Address Fax Number:
208-367-2968

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6140 CURTISIAN AVE
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83704-8880
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-367-3500
Provider Business Practice Location Address Fax Number:
208-367-2968
Provider Enumeration Date:
08/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JUTZY
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
208-367-3500

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X , with the licence number:  M5302 , 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: 806667900 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 202662100 . This is a "U S DEPARTMENT OF LABOR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 72439 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 003530200 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8K321 . This is a "BLUE CROSS OF IDAHO GROUP" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 190686 . This is a "OMAP" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 12 . This is a "WA DEPARTMENT OF LABOR" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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