1992757991 NPI number — DR. SCOTT ALAN LARSON MD

Table of content: (NPI 1942508692)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992757991 NPI number — DR. SCOTT ALAN LARSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LARSON
Provider First Name:
SCOTT
Provider Middle Name:
ALAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1992757991
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/24/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
190 E BANNOCK ST
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:
83712-6241
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:
305 E JEFFERSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83712-6231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-381-7370
Provider Business Practice Location Address Fax Number:
208-381-6911
Provider Enumeration Date:
05/17/2006

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: 207W00000X , with the licence number:  34581 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: 52876571205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: 8961062 , 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: 120085200 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 12463 . This is a "U HEALTH PLANS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: TPRA07668 . This is a "MOLINA TIN 876151902" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 100501869 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1119924 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 806733700 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: D8294 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 214773 . This is a "ALTIUS 876151902" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 52876571200001 . This is a "BCBS TIN 876151902" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 73587 . This is a "PEHP TIN 876151902" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 756072 . This is a "DMBA TIN 876151902" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 0079679 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 107018826102 . This is a "IHC TIN 876151902" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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