1184062911 NPI number — DR. JUSTIN MICHAEL WOODLIEF M.D.

Table of content: DR. JUSTIN MICHAEL WOODLIEF M.D. (NPI 1184062911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184062911 NPI number — DR. JUSTIN MICHAEL WOODLIEF M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOODLIEF
Provider First Name:
JUSTIN
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1184062911
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
169 ASHLEY AVE
Provider Second Line Business Mailing Address:
ROOM 202 MAIN HOSPITAL, MSC 333
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29425-8905
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:
520 S EAGLE RD STE 3102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-6352
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-706-5100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/14/2013

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: 207R00000X , with the licence number:  LL35928 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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