1073757464 NPI number — MICHAEL R DIBENEDETTO MD PLLC

Table of content: (NPI 1073757464)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073757464 NPI number — MICHAEL R DIBENEDETTO MD PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL R DIBENEDETTO MD 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:
Provider Other Organization Name Type Code:
6
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:
1073757464
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30544 HIGHWAY 200
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
PONDERAY
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83852-5005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-263-5900
Provider Business Mailing Address Fax Number:
208-263-1319

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30544 HIGHWAY 200
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
PONDERAY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83852-5005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-263-5900
Provider Business Practice Location Address Fax Number:
208-263-1319
Provider Enumeration Date:
04/29/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BROSNAHAN
Authorized Official First Name:
WENDY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
208-263-5900

Provider Taxonomy Codes

  • Taxonomy code: 2086S0122X , with the licence number:  M10671 , 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: DG3627 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8N834 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com