1851300503 NPI number — BRUCE J ANDERSEN MD PHD PA

Table of content: (NPI 1851300503)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851300503 NPI number — BRUCE J ANDERSEN MD PHD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRUCE J ANDERSEN MD PHD PA
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:
1851300503
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6140 CURTISIAN AVE
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83704-8880
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-367-3500
Provider Business Mailing Address Fax Number:
208-367-2968

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6140 CURTISIAN AVE
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83704-8880
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-367-3500
Provider Business Practice Location Address Fax Number:
208-367-2968
Provider Enumeration Date:
08/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSEN
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
208-367-3500

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X , with the licence number:  M7767 , 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: 72504 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 145403 . This is a "WA DEPARTMENT OF LABOR" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 805457400 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 134024 . This is a "OMAP" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 185529500 . This is a "US DEPARTMENT OF LABOR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000010026334 . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8J703 . This is a "BLUE CROSS OF IDAHO GROUP" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 87732500 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com