1780677369 NPI number — STEVEN C REITZ CRNA

Table of content: STEVEN C REITZ CRNA (NPI 1780677369)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780677369 NPI number — STEVEN C REITZ CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REITZ
Provider First Name:
STEVEN
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1780677369
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1233 SADDLE RIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIOLA
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83872-9772
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-883-3406
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSCOW
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83843-3056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-883-4511
Provider Business Practice Location Address Fax Number:
208-883-6571
Provider Enumeration Date:
08/29/2005

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: 367500000X , with the licence number:  AP30006755 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: RNA-632 , 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: A4381 . This is a "BC ID" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 807070200 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9642851 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00372632 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: N434380 . This is a "IDAHO LICENSE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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