1679644397 NPI number — MICHAEL RAYMOND DIBENEDETTO M.D.

Table of content: MICHAEL RAYMOND DIBENEDETTO M.D. (NPI 1679644397)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679644397 NPI number — MICHAEL RAYMOND DIBENEDETTO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIBENEDETTO
Provider First Name:
MICHAEL
Provider Middle Name:
RAYMOND
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1679644397
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30544 HIGHWAY 200
Provider Second Line Business Mailing Address:
STE 102
Provider Business Mailing Address City Name:
PONDERAY
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83852-5005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-265-9817
Provider Business Mailing Address Fax Number:
208-265-4533

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30544 HIGHWAY 200
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
PONDERAY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83852-5005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-265-9817
Provider Business Practice Location Address Fax Number:
208-265-4533
Provider Enumeration Date:
11/13/2006

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: 207X00000X , with the licence number:  M8578 , 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: 77010 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 806452000 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00042698 . This is a "PALMETTOGBA RAILROAD MEDI" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010140056 . This is a "REGENCE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com