=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962498568
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT T WECHSLER MD, PHD, FAAN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2005
-----------------------------------------------------
Last Update Date | 01/07/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1499 W. HAYS ST.
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-275-8585
-----------------------------------------------------
Fax | 208-275-8586
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1499 WEST HAYS STREET
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-381-7353
-----------------------------------------------------
Fax | 208-381-7354
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0600X
-----------------------------------------------------
Taxonomy Name | Clinical Neurophysiology Physician
-----------------------------------------------------
License Number | M9221
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------