Michael R Dibenedetto MD PLLC
Organization Active NPI Orthopaedic Surgery Physician · Ponderay, ID
NPI 1083809727 · NPPES record last updated Jun 30, 2026
Key facts
- NPI
- 1083809727
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Orthopaedic Surgery Physician 207X00000X
- Legal business name
- MICHAEL R DIBENEDETTO MD PLLC
- Practice address
- 30544 Hwy 200
Ste 102
Ponderay, ID 83852 - Phone
- (208) 265-9836
- Fax
- (208) 263-7249
- NPI assigned
- Sep 6, 2007
- Organization subpart
- No
Authorized official
- Name
- Kirsten Eveland
- Title
- Practice Manager
- Phone
- (208) 265-9817
Subparts reporting this organization as parent 1
Corporate family (same tax ID) 1
Practitioners 17
-
Joan M Bloom, M.D.
-
Audrey L Buck, RD
-
Kate Elizabeth Reidy, FNP-C
-
Travis Lee Taylor, FNP-C, CRNFA
-
Lisa Amy Galasso, MD
-
Sarah Derrig, NP
-
Justin Henderson, NP
-
Jill Suhy Stiller, ARNP-CNP
-
Darwin L Hurst, FNP
-
Ronald D Jenkins, MD
-
Susan Marie Ashford Tucker, M.S., R.D.
-
Samantha Ann Fisher, RD, LD
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 13D1050770 | Woodlands Family Medicine | Provider-performed microscopy | Feb 12, 2028 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (3 enrollments) in ID
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20071009000187 | ID | Part B Supplier - Clinic/Group Practice | 0840385670 |
Receives reassigned benefits from 14 practitioners Practice locations: Ponderay, ID; Sandpoint, ID |
| O20100930060806 | ID | DME Supplier - Physician - General Practice | 0840385670 | Practice locations: Ponderay, ID |
| O20210113002323 | ID | Part B Supplier - Intensive Cardiac Rehabilitation | 0840385670 |
Receives reassigned benefits from 2 practitioners Practice locations: Ponderay, ID |
National Provider Directory
- Tax ID family
- Michael R Dibenedetto MD PLLC
Locations
30544 Highway 200
Ste 101
Ponderay, ID 83852
Phone (208) 263-6300
30544 Highway 200
Ste 103
Ponderay, ID 83852
Phone (208) 946-5110
30544 Highway 200
Ste 301
Ponderay, ID 83852
Phone (208) 263-6300
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Orthopaedic Surgery Physician |
207X00000X | Yes | ||
| Cardiac Rehabilitation Clinic/Center | 261QR0404X |
Addresses
Primary practice location
30544 Hwy 200
Ste 102
Ponderay, ID 83852
Mailing address
30544 Highway 200 Ste 102
Ponderay, ID 83852-5005
Phone (208) 265-9817
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| DG3627 | Other | ID | PALMETTO GBA RAILROAD MED |
| 806452000 | Medicaid | ID | |
| 000010140056 | Other | ID | REGENCE BLUE SHIELD |
| 8N259 | Other | ID | BLUE CROSS |
Other names
- North Idaho Cardiac Rehabilitation
- North Idaho Orthopedics & Sports Medicine
- Woodlands Family Medicine
Other providers in Ponderay, ID
- Adelaida Mahler
- Kim C Marley
- Matthew Wittwer Chiropractic, P.L.L.C.
- Amy McGrath
- Michael R Dibenedetto MD PLLC
- Nicholas G Miller
- Amber C Moir-Brow
- Joshua Robert Moore
- Nora Morrison
- Melinda Elizabeth Helen Murray
All providers in Ponderay, ID · Orthopaedic Surgery Physician in Idaho
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 30, 2026. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.