NPIMap

Organization Active NPI

Ridgeline Medical LLC

  • Family Medicine Physician
  • Idaho Falls, ID
National Provider Identifier
1386110963
Registry record updated Nov 1, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
RIDGELINE MEDICAL LLC
Doing business as
Ridgeline Medical LLC
Practice address
2470 Jafer CT
Idaho Falls, ID 83404-5587
Phone
(208) 715-9990
Fax
(208) 715-9992
NPI assigned
Oct 22, 2018
Last updated
Nov 1, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 1, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Martin Mangan, DONPI 1972709103
Title
Owner
Phone
(208) 715-9990

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 5

Specialty (taxonomy)CodeLicenseStatePrimary
Chiropractor 111N00000X NU
Family Medicine Physician 207Q00000X NU Primary
Physical Medicine & Rehabilitation Physician 208100000X NU
Urgent Care Clinic/Center 261QU0200X NU
Sleep Medicine (Family Medicine) Physician 207QS1201X NU

Addresses

Primary practice location

2470 Jafer CT
Idaho Falls, ID 83404-5587

Mailing address

2429 Jafer CT
Idaho Falls, ID 83404-5587
Phone (208) 715-9990

Other names 1

  • Ridgeline Medical LLC Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20190227001380 ID Part B Supplier - Clinic/Group Practice 5092054551 Receives reassigned benefits from 13 practitioners
Practice locations: Idaho Falls, ID

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
13D2162276Ridgeline Medical2470 Jafer CT, Idaho Falls, ID 83404Certificate of waiverApr 11, 2028

National Provider Directory

National Provider Directory

Locations

2429 Jafer Ct
Idaho Falls, ID 83404
Phone (208) 712-7077

Practitioners & affiliated clinicians

Practitioners 13

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 13

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1540166400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1635724800000",
    "number": "1386110963",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2429 JAFER CT",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834045587",
            "telephone_number": "208-715-9990",
            "fax_number": "208-715-9992"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2470 JAFER CT",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834045587",
            "telephone_number": "208-715-9990",
            "fax_number": "208-715-9992"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RIDGELINE MEDICAL LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-10-22",
        "last_updated": "2021-11-01",
        "certification_date": "2021-11-01",
        "status": "A",
        "authorized_official_last_name": "MANGAN",
        "authorized_official_first_name": "MARTIN",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "208-715-9990",
        "authorized_official_credential": "DO"
    },
    "taxonomies": [
        {
            "code": "111N00000X",
            "taxonomy_group": "",
            "desc": "Chiropractor",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "208100000X",
            "taxonomy_group": "",
            "desc": "Physical Medicine & Rehabilitation",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QU0200X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Urgent Care",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207QS1201X",
            "taxonomy_group": "",
            "desc": "Family Medicine, Sleep Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Ridgeline Medical LLC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Idaho Falls, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 1, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.