Provider Demographics
NPI:1215061734
Name:BOISE VALLEY ASTHMA & ALLERGY PA
Entity type:Organization
Organization Name:BOISE VALLEY ASTHMA & ALLERGY PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INSURANCE/CREDENTIALING ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:MARYANN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-378-0080
Mailing Address - Street 1:901 N CURTIS RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-1394
Mailing Address - Country:US
Mailing Address - Phone:208-378-0080
Mailing Address - Fax:208-378-0259
Practice Address - Street 1:901 N CURTIS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1394
Practice Address - Country:US
Practice Address - Phone:208-378-0080
Practice Address - Fax:208-378-0259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1374345OtherMEDICARE PTAN
ID1215061734Medicaid
IDS87885Medicare UPIN
ID1129076Medicare ID - Type Unspecified
ID1130829Medicare ID - Type Unspecified
ID1143164Medicare ID - Type Unspecified
ID1215061734Medicaid
ID1342591Medicare ID - Type Unspecified
IDH53419Medicare UPIN
IDH53419Medicare UPIN