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General NPI Number Information
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NPI Number | 1144887050
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Entity Type | Organization
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Legal Business Name | ST MICHAEL NEPHROLOGY, PLLC
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Dates
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Enumeration Date | 05/26/2019
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Last Update Date | 07/14/2019
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Provider Practice Location Address
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Address Line | 1674 S LOGGERS POND PL APT 14
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City | BOISE
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State | ID
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Zip | 83706-7517
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Country | US
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Telephone | 986-200-8202
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Fax | 626-593-4751
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Provider Business Mailing Address
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Address Line | 999 W MAIN ST STE 100
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City | BOISE
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State | ID
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Zip | 83702-9001
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | NEPHROLOGIST
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Name | DR. ERNEST DANIEL MORENO DYTIAPCO
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Credential | MD
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Telephone | 986-200-8202
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number |
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License Number State |
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