Basic Information
| Provider Information | |||||||||
| NPI: | 1295890648 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLACKMER FOOT & ANKLE GROUP PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTH IDAHO FOOT AND ANKLE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 16820 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837156820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083239130 | ||||||||
| FaxNumber: | 2083239070 | ||||||||
| Practice Location | |||||||||
| Address1: | 191 ADDISON AVE | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833015177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087333881 | ||||||||
| FaxNumber: | 2087348441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2006 | ||||||||
| LastUpdateDate: | 03/28/2011 | ||||||||
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| AuthorizedOfficialLastName: | BLACKMER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2087333881 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.