1730190836 NPI number — DR. MATTHEW R MACHA MD

Table of content: DR. MATTHEW R MACHA MD (NPI 1730190836)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730190836 NPI number — DR. MATTHEW R MACHA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MACHA
Provider First Name:
MATTHEW
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1730190836
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2045
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAGLE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83616-9110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-343-5600
Provider Business Mailing Address Fax Number:
208-779-2898

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
323 E RIVERSIDE DR STE 220
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAGLE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83616-5246
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-343-5600
Provider Business Practice Location Address Fax Number:
208-779-2898
Provider Enumeration Date:
08/11/2006

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: 208600000X , with the licence number:  M6834 , 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: 000010001037 . This is a "REGENCE BS BOI" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010144925 . This is a "REGENBE BS MTN HOME" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 020030135 . This is a "TRICARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 002279400 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: B3861 . This is a "BLUE CROSS OF ID EMMETT" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010149831 . This is a "REGENCE BS EMMETT" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: B3879 . This is a "BC OF IDAHO MTN HOME" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 70334 . This is a "BLUE CROSS OF IDAHO BOIS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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