Active NPI
Nic R Cordum, M.D.
- Gastroenterology Physician
- Boise, ID
National Provider Identifier
1205803756
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Gastroenterology Physician
- License
- M6979
- Practice address
- 6259 W Emerald St
Boise, ID 83704-8731 - Phone
- (208) 489-1900
- Fax
- (208) 375-5286
- NPI assigned
- Mar 3, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Gastroenterology Physician | 207RG0100X | M6979 | ID | Primary |
Addresses
Primary practice location
6259 W Emerald St
Boise, ID 83704-8731
Mailing address
6259 W Emerald St
Boise, ID 83704-8731
Phone (208) 489-1900
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| M6979 | ID | MD | Gastroenterology Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1141344000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1189123200000",
"number": "1205803756",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "6259 W EMERALD ST",
"city": "BOISE",
"state": "ID",
"postal_code": "837048731",
"telephone_number": "208-489-1900",
"fax_number": "208-375-5286"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "6259 W EMERALD ST",
"city": "BOISE",
"state": "ID",
"postal_code": "837048731",
"telephone_number": "208-489-1900",
"fax_number": "208-375-5286"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CORDUM",
"first_name": "NIC",
"middle_name": "R",
"name_prefix": "Dr.",
"credential": "M.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-03-03",
"last_updated": "2007-09-07",
"status": "A"
},
"taxonomies": [
{
"code": "207RG0100X",
"taxonomy_group": "",
"desc": "Internal Medicine, Gastroenterology",
"state": "ID",
"license": "M6979",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Boise, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 7, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.