1588861405 NPI number — PODIATRY SERVICES OF IDAHO, PLLC

Table of content: (NPI 1588861405)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588861405 NPI number — PODIATRY SERVICES OF IDAHO, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PODIATRY SERVICES OF IDAHO, PLLC
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:
1588861405
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1105 E USTICK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CALDWELL
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83605-6306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-402-6587
Provider Business Mailing Address Fax Number:
208-402-6578

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
229 E LOGAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CALDWELL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83605-4835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-402-6587
Provider Business Practice Location Address Fax Number:
84-026-5782
Provider Enumeration Date:
07/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HARRIS
Authorized Official First Name:
CAMILLE
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
208-402-6587

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  DP00359 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 023111 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00251554 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: DD5083 . This is a "RAILROAD MEDICARE GROUP NUMBER" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 4540570001 . This is a "MEDICARE DMERC" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 807150700 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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