1396916789 NPI number — MERCY PHYSICIAN GROUP, INC.

Table of content: MRS. DOMINIQUE M BEAUFILS-BREHM PT (NPI 1487642344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396916789 NPI number — MERCY PHYSICIAN GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERCY PHYSICIAN GROUP, INC.
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:
1396916789
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4400 E FLAMINGO AVE
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
NAMPA
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83687-9203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-465-6970
Provider Business Mailing Address Fax Number:
208-465-6990

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4400 E FLAMINGO AVE
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
NAMPA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83687-9203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-465-6970
Provider Business Practice Location Address Fax Number:
208-465-6990
Provider Enumeration Date:
03/13/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MCCLURE
Authorized Official First Name:
DENISE
Authorized Official Middle Name:
C
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
208-463-5549

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com