1487854055 NPI number — MRS. PAMELA KOTHARI DENSON MD

Table of content: SARAH K HEIL-BRENNY MSW, LICSW (NPI 1366830622)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487854055 NPI number — MRS. PAMELA KOTHARI DENSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DENSON
Provider First Name:
PAMELA
Provider Middle Name:
KOTHARI
Provider Name Prefix Text:
MRS.
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:
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:
1487854055
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2001 S WOODRUFF AVE
Provider Second Line Business Mailing Address:
SUITE 10
Provider Business Mailing Address City Name:
IDAHO FALLS
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83404-6374
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-206-0527
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 S WOODRUFF AVE
Provider Second Line Business Practice Location Address:
SUITE 10
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404-6374
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-885-0828
Provider Business Practice Location Address Fax Number:
417-886-7383
Provider Enumeration Date:
07/23/2007

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: 207V00000X , with the licence number: N5163 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 2012007463 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: M-12616 , 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)

  • Identifier: 1487854055 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 431560263 . This is a "TRICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 194646001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01128235 . This is a "RR MCR" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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