1144200916 NPI number — DR. JOEL ANDREW CARLSON DO

Table of content: DR. JOEL ANDREW CARLSON DO (NPI 1144200916)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144200916 NPI number — DR. JOEL ANDREW CARLSON DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARLSON
Provider First Name:
JOEL
Provider Middle Name:
ANDREW
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1144200916
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
777 HOSPITAL WAY
Provider Second Line Business Mailing Address:
BLDG A SUITE 300
Provider Business Mailing Address City Name:
POCATELLO
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83201-5176
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-233-1720
Provider Business Mailing Address Fax Number:
208-239-3403

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
777 HOSPITAL WAY
Provider Second Line Business Practice Location Address:
BLDG A SUITE 300
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-5176
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-233-1720
Provider Business Practice Location Address Fax Number:
208-239-3403
Provider Enumeration Date:
01/18/2006

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: 207V00000X , with the licence number:  3140 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: O-0407 , 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: S6109 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010156981 . This is a "REGENCE-BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 807508700 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 546490 . This is a "DESERET MUTUAL" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: P00355281 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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