1124115944 NPI number — TONY C ROISUM MD PA

Table of content: (NPI 1124115944)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124115944 NPI number — TONY C ROISUM MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TONY C ROISUM MD 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:
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:
1124115944
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
07/24/2007
NPI Reactivation Date:
12/09/2008

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3360 WASHINGTON PKWY
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
IDAHO FALLS
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83404-8333
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-524-3416
Provider Business Mailing Address Fax Number:
208-524-3138

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3360 WASHINGTON PKWY
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404-8333
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-524-3416
Provider Business Practice Location Address Fax Number:
208-524-3138
Provider Enumeration Date:
10/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROISUM
Authorized Official First Name:
TONY
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER / PRESIDENT
Authorized Official Telephone Number:
208-524-3416

Provider Taxonomy Codes

  • Taxonomy code: 207QS0010X , with the licence number:  M7389 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: M7389 , 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: 000010004286 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: B5824 . This is a "BLUE CROSS" identifier . This identifiers is of the category "OTHER".
  • Identifier: DJ475 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 119166700 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 185461600 . This is a "US DEPT OF LABOR" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 502862456001 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 23397 . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 805076700 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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