Healthcare Provider Details

I. General information

NPI: 1083809727
Provider Name (Legal Business Name): MICHAEL R DIBENEDETTO MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 05/07/2021
Certification Date: 05/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30544 HWY 200 STE 102
PONDERAY ID
83852
US

IV. Provider business mailing address

30544 HWY 200 STE 102
PONDERAY ID
83852
US

V. Phone/Fax

Practice location:
  • Phone: 208-265-9836
  • Fax: 208-263-7249
Mailing address:
  • Phone: 208-265-9817
  • Fax: 208-263-7249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0404X
TaxonomyCardiac Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DANIEL P GARMAN
Title or Position: PRACTICE MANAGER
Credential:
Phone: 208-265-9817