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General NPI Number Information
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NPI Number | 1578726683
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Entity Type | Individual
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Provider Name | BLAKE D NIEDERHAUSER MD
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Gender | Male
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Dates
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Enumeration Date | 07/08/2008
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Last Update Date | 01/10/2018
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Provider Practice Location Address
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Address Line | 190 E BANNOCK ST
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City | BOISE
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State | ID
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Zip | 83712-6241
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Country | US
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Telephone | 208-381-2094
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Fax | 208-381-1791
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Provider Business Mailing Address
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Address Line | PO BOX 1108
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City | CORVALLIS
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State | OR
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Zip | 97339-1108
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Country | US
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Telephone | 208-381-2094
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Fax | 208-381-1791
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 104451
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 52314
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License Number State | MN
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Taxonomy #3
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | M-12384
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License Number State | ID
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