Basic Information
| Provider Information | |||||||||
| NPI: | 1962783233 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOISE FOOT AND ANKLE GROUP | ||||||||
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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: | 727 E RIVERPARK LN | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837064069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083190497 | ||||||||
| FaxNumber: | 2083239070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2011 | ||||||||
| LastUpdateDate: | 08/31/2011 | ||||||||
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| AuthorizedOfficialLastName: | BLACKMER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2083190497 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BLACKMER FOOT AND ANKLE GROUP PA | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213EP1101X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine |
No ID Information.