1346205937 NPI number — M ANDREW MIX RPT

Table of content: M ANDREW MIX RPT (NPI 1346205937)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346205937 NPI number — M ANDREW MIX RPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIX
Provider First Name:
M ANDREW
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RPT
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:
1346205937
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
276 EASTLAND DR N
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:
83301-4458
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-735-8563
Provider Business Mailing Address Fax Number:
208-735-8564

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
276 EASTLAND DR N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TWIN FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83301-4458
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-735-8563
Provider Business Practice Location Address Fax Number:
208-735-8564
Provider Enumeration Date:
04/18/2006

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: 225100000X , with the licence number:  PT-1352 , 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: 000010141846 . This is a "REGENCE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 806571300 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: T7275 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 806555000 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00045805 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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