MEDICARE: IDAHO DEPT OF HEALTH & WELFARE ITP REGION 4

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
1	251300000X	Local Education Agency (LEA)
2	252Y00000X	Early Intervention Provider Agency		ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	000010019044	OTHER	ID	BLUE SHIELD
3	HW306	OTHER	ID	BLUE CROSS OF IDAHO

General Provider Information

NPI Number	:	1568502409
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDAHO DEPT OF HEALTH & WELFARE ITP REGION 4

Provider Business Mailing Address
First Line	:	1720 WESTGATE DR
Second Line	:	SUITE B-2
City	:	BOISE
State	:	ID
Zip	:	83704-7164
Country	:	US
Telephone Number	:	208-334-0900
Fax Number	:	208-334-0926

Provider Business Practice Location Address
First Line	:	1720 WESTGATE DR
Second Line	:	SUITE B-2
City	:	BOISE
State	:	ID
Zip	:	83704-7164
Country	:	US
Telephone Number	:	208-334-0900
Fax Number	:	208-334-0926

Authorized Official
Title or Position	:	PROGRAM MANAGER
Name	:	MARY J JONES
Credential	:	B.U.S.
Telephone Number	:	208-334-5523

Provider Enumeration Date	:	02/08/2007
Last Update Date	:	08/05/2013

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Directions to “IDAHO DEPT OF HEALTH & WELFARE ITP REGION 4 ” Practice Location

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