Mountain West Derm-Blackhart, PLLC
Organization Active NPI Dermatology Physician · Boise, ID
NPI 1548758501 · NPPES record last updated Apr 25, 2018
Key facts
- NPI
- 1548758501
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Dermatology Physician 207N00000X
- Legal business name
- MOUNTAIN WEST DERM-BLACKHART, PLLC
- Practice address
- 7733 W Emerald St
Boise, ID 83704-9020 - Phone
- (208) 939-4599
- Fax
- (208) 939-5010
- NPI assigned
- Apr 25, 2018
- Organization subpart
- Yes
- Parent organization (as reported)
- MOUNTAIN WEST DERM-BLACKHART, PLLC
Authorized official
- Name
- Bret S Blackhart, MD
- Title
- Owner
- Phone
- (775) 336-3624
Other NPIs on the same Medicare enrollment 1
Other NPIs with the same Medicare PAC ID 6
Practitioners 111
-
Shawna Marie Beechinor, P.A.
-
Hilary H Hill, M.D.
-
Julie Kathleen McCardell, NURSE PRACTITIONER
-
Maggie Rose Callan, PA-C
-
Hilary L Cutler, ARNP
-
Joseph L Cvancara, M.D.
-
Paul T Dunn, M.D.
-
Courtney C. Gwinn, M.D.
-
Michael Riley Heaphy Jr., M.D.
-
Staci M Hestdalen, M.D.
-
Kevin Lowell Kiene, M.D.
-
Kathleen R Lejameyer, ARNP
-
Taylor Morten, FNP-C
-
Erin Monica Nulf, PA-C
-
Jeffrey B Shackelton, M.D.
-
Chadd Sukut, MD
-
Michael J Housley, PA-C
-
Chelsea Wood, PAC
-
Jeanne M Ellern, PAC
-
Amy Nicole Nelson, PA-C
-
Brenda Kay Wilks, PA-C
-
Jacob A Wolff, PAC MHS
-
James H Stewart, PHD, MD
-
Ryan Michael Wells, PHARM.D., M.D.
-
Lindsey Dawn Goddard, M.D.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in ID
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20180808001264 | ID | Part B Supplier - Clinic/Group Practice | 1153609813 |
Receives reassigned benefits from 29 practitioners 1 other NPI on this enrollment Practice locations: Boise, ID; Coeur D Alene, ID |
National Provider Directory
- Part of
- Mountain W Derm- Blackhart
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dermatology Physician |
207N00000X | Yes |
Addresses
Primary practice location
7733 W Emerald St
Boise, ID 83704-9020
Mailing address
201 Franklin Rd FL 3
Brentwood, TN 37027-5214
Phone (615) 309-2636
Other names
- Dermatology Clinic of Idaho
Other providers in Boise, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 25, 2018. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.