Basic Information
| Provider Information | |||||||||
| NPI: | 1548758501 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOUNTAIN WEST DERM-BLACKHART, PLLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | DERMATOLOGY CLINIC OF IDAHO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 201 FRANKLIN RD FL 3 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153092636 | ||||||||
| FaxNumber: | 6153092536 | ||||||||
| Practice Location | |||||||||
| Address1: | 7733 W EMERALD ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837049020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089394599 | ||||||||
| FaxNumber: | 2089395010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2018 | ||||||||
| LastUpdateDate: | 04/25/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BLACKHART | ||||||||
| AuthorizedOfficialFirstName: | BRET | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7753363624 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MOUNTAIN WEST DERM-BLACKHART, PLLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.