Elmer G Dodge Jr., FNP

Primary specialty

Nurse PractitionerTaxonomy code 363L00000X

License

NP-534A Issued in ID

Practice address

9858 W State St
Star, ID 83669-5210

Phone

(208) 286-0666

Fax

(208) 286-0565

NPI assigned

Jan 16, 2007

Sex

Male

Sole proprietor

No

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

Specialties & licenses 2

Addresses

Other identifiers 3

Medicare fee-for-service enrollment

Enrolled in ID

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

Practice roles

Locations

Interoperability endpoints

• FHIR API: https://api.platform.athenahealth.com/16529/brand/1/csg/1/fhir/r4
• Direct secure messaging: elmer.dodge.1@16529.direct.athenahealth.com

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Black Canyon Medical Group PLLC

  • Family Medicine Physician
  • Emmett, ID
  • NPI 1811419708

  ID

  Medicare reassignment NPD

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

{
    "created_epoch": "1168905600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1598918400000",
    "number": "1508918236",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 44267",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837110267",
            "telephone_number": "208-286-0666",
            "fax_number": "208-286-0565"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9858 W STATE ST",
            "city": "STAR",
            "state": "ID",
            "postal_code": "836695210",
            "telephone_number": "208-286-0666",
            "fax_number": "208-286-0565"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DODGE",
        "first_name": "ELMER",
        "middle_name": "G",
        "name_suffix": "Jr.",
        "credential": "FNP",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-01-16",
        "last_updated": "2020-09-01",
        "certification_date": "2020-09-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "163WG0000X",
            "taxonomy_group": "",
            "desc": "Registered Nurse, General Practice",
            "state": "ID",
            "license": "NP534A",
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "ID",
            "license": "NP-534A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS OF IDAHO",
            "identifier": "NPQP7",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "REGENCE BLUE SHIELD OF ID",
            "identifier": "000010150031",
            "state": "ID"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "806045400",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Stephen Rodney Crane, D.C.
• Lindsey E. Decloss, M.S.P.T.
• Melinda Demember
• Carson Steven Dial, DMD
• Direct Surgical Assist PA
• Robert W Driscoll, PT
• Elevate Chiropractic
• Ellen Ferrenburg
• Jessica Florian
• Maya S Gough

• All providers in Star, ID
• Nurse Practitioner in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 1, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.