1902937196 NPI number — PAYETTE LAKES MEDICAL CLINIC, PA

Table of content: (NPI 1902937196)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902937196 NPI number — PAYETTE LAKES MEDICAL CLINIC, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAYETTE LAKES MEDICAL CLINIC, PA
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:
DONNELLY MEDICAL CLINIC
Provider Other Organization Name Type Code:
5
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:
1902937196
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1047
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCCALL
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83638-1047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-325-4455
Provider Business Mailing Address Fax Number:
208-325-4466

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
454 ROSEBURY ROAD
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
DONNELLY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-325-4455
Provider Business Practice Location Address Fax Number:
208-325-4466
Provider Enumeration Date:
03/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BRUNS
Authorized Official First Name:
JACQUELINE
Authorized Official Middle Name:
R
Authorized Official Title or Position:
VP - PHYSICIAN SERVICES
Authorized Official Telephone Number:
208-634-4061

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8N006 . This is a "BC" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010160243 . This is a "BS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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