Healthcare Provider Details

I. General information

NPI: 1730448176
Provider Name (Legal Business Name): RACHEL ELIZABETH HENEGHAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2012
Last Update Date: 01/30/2024
Certification Date: 01/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 N 1ST ST STE 280
BOISE ID
83702-6132
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-345-6545
  • Fax: 208-345-1213
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number63855
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number01086105A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberM-17496
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: