Individual Professional Information |
|
NPI
|
1407985278
|
|
Unique healthcare provider (clinician) ID assigned by NPPES
|
|
PECOS UID
|
8325171689
|
|
Unique individual clinician ID assigned by PECOS
|
|
Professional Enrollment ID
|
I20100806000484
|
|
Unique ID for the individual professional enrollment that is the source for the data in the observation
|
|
Provider Last Name
|
BALL
|
|
Individual professional last name
|
|
Provider First Name
|
GREGORY
|
|
Individual professional first name
|
|
Provider Middle Name
|
R
|
|
Individual professional middle name
|
|
Provider Gender
|
M
|
|
The provider's gender if the provider is a person.
|
Medical School Information |
|
Medical School Name
|
AT STILL UNIVERSITY OF HEALTH SCIENCES, COLLEGE OF OSTEO MED, KIRKSVILLE
|
|
Individual professional's medical school
|
|
Graduation Year
|
2004
|
|
Individual professional's medical school graduation year
|
|
Primary Specialty
|
PULMONARY DISEASE
|
|
Primary medical specialty reported by the individual professional in the selected enrollment
|
|
Secondary Specialty 1
|
CRITICAL CARE (INTENSIVISTS)
|
|
First secondary medical specialty reported by the individual professional in the selected enrollment
|
|
All Secondary Specialties
|
CRITICAL CARE (INTENSIVISTS)
|
|
All four secondary specialties reported by the individual professional in the selected enrollment, separated by commas
|
Practice Information |
|
Organization Legal Name
|
ST LUKE'S CLINIC LLC
|
|
Legal name of the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
|
|
Group Practice PAC ID
|
1052217478
|
|
Unique Group Practice ID assigned by PECOS to the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
|
|
Number of Group Practice members
|
226
|
|
Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
|
|
Line 1 Street Address
|
775 POLE LINE RD W
|
|
Group Practice or individual's line 1 address
|
|
Marker of address line 2 suppression
|
Y
|
|
Marker that address as reported may be incomplete
|
|
City
|
TWIN FALLS
|
|
Group Practice or individual's city
|
|
State
|
ID
|
|
Group Practice or individual's state
|
|
Zip Code
|
833015823
|
|
Group Practice or individual's zip code (9 digits when available)
|
Hospital(s) Affiliation Information |
|
Hospital Affiliation CCN 1
|
130002
|
|
Medicare CCN of hospital where individual professional provides service 1
|
|
Hospital Affiliation LBN 1
|
ST LUKES MAGIC VALLEY MEDICAL CENTER
|
|
Legal business name of hospital where individual professional provides service 1
|
|
Hospital Affiliation CCN 2
|
131323
|
|
Medicare CCN of hospital where individual professional provides service 2
|
|
Hospital Affiliation LBN 2
|
ST LUKE'S WOOD RIVER MEDICAL CENTER
|
|
Legal business name of hospital where individual professional provides service 2
|
|
Hospital Affiliation CCN 3
|
131302
|
|
Medicare CCN of hospital where individual professional provides service 3
|
|
Hospital Affiliation LBN 3
|
NORTH CANYON MEDICAL CENTER
|
|
Legal business name of hospital where individual professional provides service 3
|
|
Professional Accepts Medicare Assignment
|
Y
|
|
|