1336392448 NPI number — INTERMOUNTAIN ORTHOPAEDIC PLLC

Table of content: (NPI 1336392448)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336392448 NPI number — INTERMOUNTAIN ORTHOPAEDIC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERMOUNTAIN ORTHOPAEDIC PLLC
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:
1336392448
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8886
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-8886
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 N. ROBBINS RD
Provider Second Line Business Practice Location Address:
STE 401
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83702-4539
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-383-0201
Provider Business Practice Location Address Fax Number:
208-489-4300
Provider Enumeration Date:
11/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KING
Authorized Official First Name:
HOWARD
Authorized Official Middle Name:
ARTHUR
Authorized Official Title or Position:
OWNER/PARTNER
Authorized Official Telephone Number:
208-383-0201

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DP2117 . This is a "MEDICARE RR" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 88815 . This is a "BLUECROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010006178 . This is a "BLUESHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 614389500 . This is a "OWCP" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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