1255321261 NPI number — CHRISTIAN P VETSCH MD

Table of content: CHRISTIAN P VETSCH MD (NPI 1255321261)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255321261 NPI number — CHRISTIAN P VETSCH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VETSCH
Provider First Name:
CHRISTIAN
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VETSCH
Provider Other First Name:
CHRIS
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1255321261
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
190 E BANNOCK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83712-6241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-381-2222
Provider Business Mailing Address Fax Number:
208-463-3044

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 E HAWAII AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NAMPA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83686-6011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-463-3141
Provider Business Practice Location Address Fax Number:
208-463-3044
Provider Enumeration Date:
10/21/2005

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:  M6472 , 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: J66180 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 14720 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010003578 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 020023224 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000010027644 . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000010138645 . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 002366500 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: S5119 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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