Provider Demographics
NPI:1144887050
Name:ST MICHAEL NEPHROLOGY, PLLC
Entity type:Organization
Organization Name:ST MICHAEL NEPHROLOGY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NEPHROLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ERNEST DANIEL
Authorized Official - Middle Name:MORENO
Authorized Official - Last Name:DYTIAPCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:986-200-8202
Mailing Address - Street 1:999 W MAIN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-9001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1674 S LOGGERS POND PL APT 14
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-7517
Practice Address - Country:US
Practice Address - Phone:986-200-8202
Practice Address - Fax:626-593-4751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-26
Last Update Date:2019-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty