1275655995 NPI number — ID DEPT OF HEALTH & WELFARE CSHP (GEN)

Table of content: (NPI 1275655995)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275655995 NPI number — ID DEPT OF HEALTH & WELFARE CSHP (GEN)

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ID DEPT OF HEALTH & WELFARE CSHP (GEN)
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:
1275655995
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 83720
Provider Second Line Business Mailing Address:
4TH FLOOR
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83720-0036
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-334-4935
Provider Business Mailing Address Fax Number:
208-332-7307

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
450 W STATE ST
Provider Second Line Business Practice Location Address:
4TH FLOOR
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83702-6056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-334-4935
Provider Business Practice Location Address Fax Number:
208-332-7307
Provider Enumeration Date:
04/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FINCHER
Authorized Official First Name:
PAIGE
Authorized Official Middle Name:
Authorized Official Title or Position:
ACTING PROGRAM MANAGER
Authorized Official Telephone Number:
208-334-4935

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0028234 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000010022948 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: HW207 . This is a "BLUE CROSS OF ID" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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