Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251X0800X | Physical Therapist - Orthopedic | PT-647 | ID |
NPI | 1013137850 |
---|---|
Provider Name | Mark Morgan |
First Address | Hailey, ID 83333-1191 |
Second Address | Hailey, ID 83333-8436 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/04/2007 |
Last Update Date | 03/12/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000010025485 | BLUE SHIELD PROVIDER NUM. (01) | ID |
805397000 | (05) | ID |
P00060576 | RAILROAD MEDICARE NUMBER (01) | ID |
T6251 | BLUE CROSS PROVIDER NUM. (01) | ID |