1497774772 NPI number — ANTHONY MAISIN BUONCRISTIANI, MD

Table of content: (NPI 1497774772)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497774772 NPI number — ANTHONY MAISIN BUONCRISTIANI, MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANTHONY MAISIN BUONCRISTIANI, MD
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:
6
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:
1497774772
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1332
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUN VALLEY
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83353-1332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-622-3312
Provider Business Mailing Address Fax Number:
208-622-4919

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
660 2ND AVE S
Provider Second Line Business Practice Location Address:
UNIT A
Provider Business Practice Location Address City Name:
KETCHUM
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-622-3312
Provider Business Practice Location Address Fax Number:
208-622-4919
Provider Enumeration Date:
07/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BUONCRISTIANI
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
208-622-3312

Provider Taxonomy Codes

  • Taxonomy code: 207XX0005X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 807513700 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: DF6382 . This is a "RR MEDICARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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