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NPI Code Detail

MEDICARE: MARY HAFER, MD

MEDICARE: MARY HAFER, MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363AM0700XMedical Physician AssistantPA-895ID
2174400000XSpecialistM-7753ID

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1M-7753OTHERIDIDAHO STATE MEDICAL LICENSE

General Provider Information

NPI Number : 1154610731
Entity Type Code : Organization
Provider Name (Legal Business Name) : MARY HAFER, MD
Provider Business Mailing Address
First Line : 2971 E COPPER POINT DR
Second Line : SUITE # 125
City : MERIDIAN
State : ID
Zip : 83642-5101
Country : US
Telephone Number : 208-893-5383
Fax Number : 208-893-5386
Provider Business Practice Location Address
First Line : 2971 E COPPER POINT DR
Second Line : SUITE # 125
City : MERIDIAN
State : ID
Zip : 83642-5101
Country : US
Telephone Number : 208-893-5383
Fax Number : 208-893-5386
Authorized Official
Title or Position : OFFICE MANAGER
Name : MICHELE JANEE LOUCAO
Credential :
Telephone Number : 208-893-5383
Provider Enumeration Date : 04/04/2011
Last Update Date : 04/04/2011

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