1396868501 NPI number — ID DEPT OF HEALTH & WELFARE CSHP (SLC)

Table of content: DR. KRISTEN R. AVERSA MD (NPI 1538153788)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396868501 NPI number — ID DEPT OF HEALTH & WELFARE CSHP (SLC)

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ID DEPT OF HEALTH & WELFARE CSHP (SLC)
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:
1396868501
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:
100 E IDAHO ST
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83712-6223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-381-7092
Provider Business Practice Location Address Fax Number:
208-381-7002
Provider Enumeration Date:
04/10/2007

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: HW207 . This is a "BLUE CROSS OF ID" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010022948 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8058529 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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