1194817023 NPI number — TREASURE VALLEY GASTROENTEROLOGY SPECIALISTS INC

Table of content: (NPI 1194817023)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194817023 NPI number — TREASURE VALLEY GASTROENTEROLOGY SPECIALISTS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TREASURE VALLEY GASTROENTEROLOGY SPECIALISTS INC
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:
1194817023
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
222 W IOWA AVE
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
NAMPA
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83686-6813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-467-3432
Provider Business Mailing Address Fax Number:
208-467-4147

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
222 W IOWA AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
NAMPA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83686-6813
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-467-3432
Provider Business Practice Location Address Fax Number:
208-467-4147
Provider Enumeration Date:
09/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CROITORU
Authorized Official First Name:
RAQUEL
Authorized Official Middle Name:
Authorized Official Title or Position:
GASTROENTEROLOGIST
Authorized Official Telephone Number:
208-467-3432

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  M-5744 , 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: 002701100 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000010006187 . This is a "REGENCE BLUE SHIELD OF ID" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 84160 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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