=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528106309
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK A RASMUS MD-PULM/SM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2007
-----------------------------------------------------
Last Update Date | 05/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7272 POTOMAC
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-884-2922
-----------------------------------------------------
Fax | 208-463-3044
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 215 E HAWAII AVE
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83686-6011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-463-3000
-----------------------------------------------------
Fax | 208-463-3064
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | M-9630
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | M9630
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------