1992834089 NPI number — STEPHEN R MARANO MD PC

Table of content: (NPI 1992834089)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992834089 NPI number — STEPHEN R MARANO MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEPHEN R MARANO MD PC
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:
6
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:
1992834089
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2375 E SUNNYSIDE RD
Provider Second Line Business Mailing Address:
STE F
Provider Business Mailing Address City Name:
IDAHO FALLS
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83404-7579
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-522-6930
Provider Business Mailing Address Fax Number:
208-523-5342

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2375 E SUNNYSIDE RD
Provider Second Line Business Practice Location Address:
STE F
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404-7579
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-522-6930
Provider Business Practice Location Address Fax Number:
208-523-5342
Provider Enumeration Date:
03/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MARANO
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
208-522-6930

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X , with the licence number:  M5076 , 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: 185584800 . This is a "ASC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 57489 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000060000 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000010002012 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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