1851493829 NPI number — MS. SUSAN M DERIVAS CNP

Table of content: MS. SUSAN M DERIVAS CNP (NPI 1851493829)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851493829 NPI number — MS. SUSAN M DERIVAS CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DERIVAS
Provider First Name:
SUSAN
Provider Middle Name:
M
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CNP
Provider Gender Code:
F

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:
1851493829
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4055 E BLUEBERRY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83642-8261
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-775-7418
Provider Business Mailing Address Fax Number:
208-674-5008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4055 E BLUEBERRY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-8261
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-775-7418
Provider Business Practice Location Address Fax Number:
208-647-5008
Provider Enumeration Date:
09/01/2006

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: 363LP0808X , with the licence number:  64266 , 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: 208-775-7418 . This is a "SPRUCE HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1032026 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5708247 . This is a "EVERNORTH" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 932434 . This is a "AVAILITY ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0062-0104069 . This is a "UNITED HEALTHCARE SERVICES, PROVIDER NO." identifier . This identifiers is of the category "OTHER".
  • Identifier: 13961493 . This is a "CAQH PROVIDER ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 909072 . This is a "CHANGE HEALTHCARE SUBMITTER ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1851493829 . This is a "CLOZAPINE REMS CERTIFIED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 396453 . This is a "MASTER BILLING ID (OSMIND)" identifier . This identifiers is of the category "OTHER".




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