1417122821 NPI number — ELMORE MEDICAL CENTER SPECIALTY PHYSICIAN GROUP

Table of content: (NPI 1417122821)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417122821 NPI number — ELMORE MEDICAL CENTER SPECIALTY PHYSICIAN GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELMORE MEDICAL CENTER SPECIALTY PHYSICIAN GROUP
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:
1417122821
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/28/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1270
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNTAIN HOME
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83647-1270
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-587-8401
Provider Business Mailing Address Fax Number:
208-587-8406

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
890 N 6TH E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNTAIN HOME
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83647-2206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-587-8401
Provider Business Practice Location Address Fax Number:
208-587-8406
Provider Enumeration Date:
04/25/2008

Additional Information

Authorized Official

Authorized Official Last Name:
JANOUSEK
Authorized Official First Name:
MARY
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
208-587-8401

Provider Taxonomy Codes

  • Taxonomy code: 282NC0060X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000010149755 . This is a "BLUE SHIELD PROF NUMBER" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000014148578 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 002860700 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8K594 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com