Idaho Falls Dermatology P a

Primary specialty

SpecialistTaxonomy code 174400000X

License

5809M Issued in ID

Legal business name

IDAHO FALLS DERMATOLOGY P A

Practice address

2001 S Woodruff Ave
Ste 12a
Idaho Falls, ID 83404-6374

Phone

(208) 522-8945

NPI assigned

Jan 25, 2007

Organization subpart

No

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

Authorized official

Name

Cornelius Paul BrookeNPI 1275504300

Title

M.D.

Phone

(208) 522-8945

Specialties & licenses 1

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in ID

Enrollment records 1

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

CLIA laboratory certificates

Locations

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Cornelius Paul Brooke, MD

  • Dermatology Physician
  • Idaho Falls, ID
  • NPI 1275504300
  Medicare reassignment NPD Authorized official
• Stetson Albertson, DO

  • Dermatology Physician
  • Warren, MI
  • NPI 1427579929

  ID

  Medicare reassignment NPD

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

{
    "created_epoch": "1169683200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1467676800000",
    "number": "1487700464",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2001 S WOODRUFF AVE",
            "address_2": "STE 12A",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834046374",
            "telephone_number": "208-522-8945"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2001 S WOODRUFF AVE",
            "address_2": "STE 12A",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834046374",
            "telephone_number": "208-522-8945"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IDAHO FALLS DERMATOLOGY P A",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-25",
        "last_updated": "2016-07-05",
        "status": "A",
        "authorized_official_last_name": "BROOKE",
        "authorized_official_first_name": "CORNELIUS",
        "authorized_official_middle_name": "PAUL",
        "authorized_official_title_or_position": "M.D.",
        "authorized_official_telephone_number": "208-522-8945"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Specialist",
            "state": "ID",
            "license": "5809M",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "807962200",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS",
            "identifier": "77186",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Idaho Falls Arthritis Clinic PC
• Idaho Falls ASC
• Idaho Falls Clinic, P.a.
• Idaho Falls Community Hospital LLC
• Idaho Falls Dental Group
• Idaho Falls Family YMCA
• Idaho Falls Group Homes
• Idaho Falls Group Homes
• Idaho Falls Group Homes
• Idaho Falls Hand Surgery

• Specialist in Idaho Falls, ID
• Providers in Idaho Falls, ID by specialty
• Specialist in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 5, 2016; 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.