NPIMap

Organization Active NPI

Eagle Dermatology, PLLC

  • Dermatology Physician
  • Eagle, ID
National Provider Identifier
1417456385
Registry record updated Feb 6, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
License
O-1094 Issued in ID
Legal business name
EAGLE DERMATOLOGY, PLLC
Practice address
323 E Riverside Dr Ste 234
Eagle, ID 83616-6865
Phone
(208) 391-7210
Fax
(208) 391-2130
NPI assigned
Feb 6, 2018
Last updated
Feb 6, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 6, 2018

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

Authorized official

Name
Mrs. Jennifer Annette Guerrero
Title
Practice Manager
Phone
(208) 391-7210

Specialties & licenses 6

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology Physician 207N00000X O-1094 ID Primary
MOHS-Micrographic Surgery Physician 207ND0101X O-1094 ID
Dermatopathology Physician 207ND0900X O-1094 ID
Clinical & Laboratory Dermatological Immunology Physician 207NI0002X O-1094 ID
Pediatric Dermatology Physician 207NP0225X O-1094 ID
Procedural Dermatology Physician 207NS0135X O-1094 ID

Addresses

Primary practice location

323 E Riverside Dr Ste 234
Eagle, ID 83616-6865

Mailing address

372 S Eagle Rd # 126
Eagle, ID 83616-5908
Phone (208) 391-7210

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20180606001883 ID Part B Supplier - Clinic/Group Practice 1658636048 Receives reassigned benefits from 4 practitioners
Practice locations: Eagle, ID

National Provider Directory

National Provider Directory

Locations

74 N Fisher Park Way
Eagle, ID 83616
Phone (208) 391-7210

Interoperability endpoints

  • FHIR API: https://app.meldrx.com/api/fhir/ez_00113

Practitioners & affiliated clinicians

Practitioners 5

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.

NPI Registry JSON

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

{
    "created_epoch": "1517875200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1517875200000",
    "number": "1417456385",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "372 S EAGLE RD # 126",
            "city": "EAGLE",
            "state": "ID",
            "postal_code": "836165908",
            "telephone_number": "208-391-7210",
            "fax_number": "208-391-2130"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "323 E RIVERSIDE DR STE 234",
            "city": "EAGLE",
            "state": "ID",
            "postal_code": "836166865",
            "telephone_number": "208-391-7210",
            "fax_number": "208-391-2130"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAGLE DERMATOLOGY, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-02-06",
        "last_updated": "2018-02-06",
        "status": "A",
        "authorized_official_last_name": "GUERRERO",
        "authorized_official_first_name": "JENNIFER",
        "authorized_official_middle_name": "ANNETTE",
        "authorized_official_title_or_position": "PRACTICE MANAGER",
        "authorized_official_telephone_number": "208-391-7210",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "ID",
            "license": "O-1094",
            "primary": true
        },
        {
            "code": "207ND0101X",
            "taxonomy_group": "",
            "desc": "Dermatology, MOHS-Micrographic Surgery",
            "state": "ID",
            "license": "O-1094",
            "primary": false
        },
        {
            "code": "207ND0900X",
            "taxonomy_group": "",
            "desc": "Dermatology, Dermatopathology",
            "state": "ID",
            "license": "O-1094",
            "primary": false
        },
        {
            "code": "207NI0002X",
            "taxonomy_group": "",
            "desc": "Dermatology, Clinical & Laboratory Dermatological Immunology",
            "state": "ID",
            "license": "O-1094",
            "primary": false
        },
        {
            "code": "207NP0225X",
            "taxonomy_group": "",
            "desc": "Dermatology, Pediatric Dermatology",
            "state": "ID",
            "license": "O-1094",
            "primary": false
        },
        {
            "code": "207NS0135X",
            "taxonomy_group": "",
            "desc": "Dermatology, Procedural Dermatology",
            "state": "ID",
            "license": "O-1094",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Eagle, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 6, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.