1336273085 NPI number — STEPHEN A DENAGY M4915

Table of content: STEPHEN A DENAGY M4915 (NPI 1336273085)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336273085 NPI number — STEPHEN A DENAGY M4915

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DENAGY
Provider First Name:
STEPHEN
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M4915
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:
1336273085
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2705 E 17TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AMMON
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83406-6601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-346-7500
Provider Business Mailing Address Fax Number:
208-346-7501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2705 E 17TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AMMON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83406-6601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-346-7500
Provider Business Practice Location Address Fax Number:
208-346-7501
Provider Enumeration Date:
03/15/2007

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:  M4915 , 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: 002648500 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: C36950 . This is a "UPIN" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010005201 . This is a "BLUE SHIELD OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 820428306 . This is a "CIGNA BEHAVIORAL HEALTH" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 1370128 . This is a "MEDICARE GROUP" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 49155 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: G526301 . This is a "TRICARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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