Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | O-225 | ID |
NPI | 1003805037 |
---|---|
Provider Name | Ben Terry |
First Address | Nampa, ID 83686-6811 |
Second Address | Nampa, ID 83687-9203 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/10/2005 |
Last Update Date | 13/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000010027473 | BLUE CROSS (01) | ID |
000010027474 | BLUE CROSS (01) | ID |
08148209 | RAILROAD MEDICARE (01) | ID |
D47180 | (02) | |
S3101 | BLUE CROSS (01) | ID |
S3119 | BLUE CROSS (01) | ID |