1386637676 NPI number — MR. BLAISE EMILE FAVARA MD

Table of content: MR. BLAISE EMILE FAVARA MD (NPI 1386637676)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386637676 NPI number — MR. BLAISE EMILE FAVARA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAVARA
Provider First Name:
BLAISE
Provider Middle Name:
EMILE
Provider Name Prefix Text:
MR.
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:
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:
1386637676
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/26/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1114 W MAIN
Provider Second Line Business Mailing Address:
SOUTH VALLEY PEDIATRICS
Provider Business Mailing Address City Name:
HAMILTON
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59840
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-363-5013
Provider Business Mailing Address Fax Number:
406-363-3714

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1114 W MAIN
Provider Second Line Business Practice Location Address:
SOUTH VALLEY PEDIATRICS
Provider Business Practice Location Address City Name:
HAMILTON
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59840
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-363-5013
Provider Business Practice Location Address Fax Number:
406-363-3714
Provider Enumeration Date:
08/23/2005

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: 208000000X , with the licence number:  MT7843 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10341 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0100487 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".