Basic Information
| Provider Information | |||||||||
| NPI: | 1154561116 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOSEPH W IPPOLITO JR MD PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 526 SHOUP AVE W | ||||||||
| Address2: | SUITE F | ||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833014591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087367620 | ||||||||
| FaxNumber: | 2087359537 | ||||||||
| Practice Location | |||||||||
| Address1: | 526 SHOUP AVE W | ||||||||
| Address2: | SUITE F | ||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833014591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087367620 | ||||||||
| FaxNumber: | 2087359537 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2009 | ||||||||
| LastUpdateDate: | 08/29/2012 | ||||||||
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| AuthorizedOfficialLastName: | IPPOLITO | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DOCTOR/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2087367620 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305R00000X | M7008 | ID | Y | Managed Care Organizations | Preferred Provider Organization |
ID Information
| ID | Type | State | Issuer | Description | 000010001696 | 01 | ID | REGENCE BLUE SHIELD OF IDAHO | OTHER | DY066 | 01 | ID | BLUE CROSS OF IDAHO | OTHER | 003755600 | 05 | ID | MEDICAID |