Provider Demographics
NPI:1205827904
Name:SEVERSON, MICHAEL D (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:SEVERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:520 S EAGLE RD
Practice Address - Street 2:SUITE 1222
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6351
Practice Address - Country:US
Practice Address - Phone:208-947-2266
Practice Address - Fax:208-947-2267
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8793207L00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP00036983OtherRAILROAD MEDICARE
ID806625400Medicaid
H87030Medicare UPIN
ID806625400Medicaid