1235167198 NPI number — BRUCE C MCCOMAS M.D.

Table of content: BRUCE C MCCOMAS M.D. (NPI 1235167198)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235167198 NPI number — BRUCE C MCCOMAS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCOMAS
Provider First Name:
BRUCE
Provider Middle Name:
C
Provider Name Prefix Text:
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:
1235167198
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 587
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TWIN FALLS
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83303-0587
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-814-7400
Provider Business Mailing Address Fax Number:
208-814-7491

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
775 POLE LINE RD W
Provider Second Line Business Practice Location Address:
SUITE 212
Provider Business Practice Location Address City Name:
TWIN FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83301-5814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-814-8400
Provider Business Practice Location Address Fax Number:
208-734-3045
Provider Enumeration Date:
06/29/2006

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: 208600000X , with the licence number:  M5070 , 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: 020048945 . This is a "MCRR - SIGS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: P00721163 . This is a "MCRR - SLC" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000369200 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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