1477167526 NPI number — MARIELLEN C VAN NIEUWENHUYZEN MD

Table of content: MARIELLEN C VAN NIEUWENHUYZEN MD (NPI 1477167526)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477167526 NPI number — MARIELLEN C VAN NIEUWENHUYZEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN NIEUWENHUYZEN
Provider First Name:
MARIELLEN
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOFLAND
Provider Other First Name:
MARIELLEN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1477167526
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
777 N RAYMOND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83704-9251
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-514-2500
Provider Business Mailing Address Fax Number:
208-375-2217

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
777 N RAYMOND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83704-9251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-514-2500
Provider Business Practice Location Address Fax Number:
208-375-2217
Provider Enumeration Date:
09/05/2020

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: MRM-2165 , 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)