1497723241 NPI number — PATHOLOGY ASSOCIATES OF IDAHO FALLS P A

Table of content: REGAN CLARESSE SILVIS PHARMD (NPI 1487399796)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497723241 NPI number — PATHOLOGY ASSOCIATES OF IDAHO FALLS P A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATHOLOGY ASSOCIATES OF IDAHO FALLS P A
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:
1497723241
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/06/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3100 CHANNING WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IDAHO FALLS
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83404-7533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-529-6111
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3100 CHANNING WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404-7533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-529-6050
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TANNENBAUM
Authorized Official First Name:
MATT
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
208-529-6050

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 002346700 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 88971 . This is a "BLUE CROSS OF ID" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010026929 . This is a "REGENCE BLUE SHIELD ID" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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