1902952930 NPI number — DR. ADAM WRAY DO

Table of content: DR. ADAM WRAY DO (NPI 1902952930)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902952930 NPI number — DR. ADAM WRAY DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WRAY
Provider First Name:
ADAM
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1902952930
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
326 POPLAR ST STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLACKFOOT
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83221-1741
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
986-275-0003
Provider Business Mailing Address Fax Number:
986-275-0005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
326 POPLAR ST STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLACKFOOT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83221-1741
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
986-275-0003
Provider Business Practice Location Address Fax Number:
986-275-0005
Provider Enumeration Date:
01/25/2007

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: 207N00000X , with the licence number:  O-0444 , 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: 000010163016 . This is a "REGENCE BLUE SHIELD POC" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: S6116 . This is a "BLUE CROSS BLKFT" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: S6117 . This is a "BLUE CROSS POC" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 807719000 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000010163015 . This is a "REGENCE BLUE SHIELD BLKFT" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 315520 . This is a "ALTIUS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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