1154610731 NPI number — MARY HAFER, MD

Table of content: (NPI 1154610731)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154610731 NPI number — MARY HAFER, MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARY HAFER, MD
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:
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:
1154610731
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2971 E COPPER POINT DR
Provider Second Line Business Mailing Address:
SUITE # 125
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83642-5101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-893-5383
Provider Business Mailing Address Fax Number:
208-893-5386

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2971 E COPPER POINT DR
Provider Second Line Business Practice Location Address:
SUITE # 125
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-5101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-893-5383
Provider Business Practice Location Address Fax Number:
208-893-5386
Provider Enumeration Date:
04/04/2011

Additional Information

Authorized Official

Authorized Official Last Name:
LOUCAO
Authorized Official First Name:
MICHELE
Authorized Official Middle Name:
JANEE
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
208-893-5383

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA-895 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , with the licence number: M-7753 , 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: M-7753 . This is a "IDAHO STATE MEDICAL LICENSE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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