NPIMap

Organization Active NPI

Mountain West Derm-Blackhart, PLLC

Doing business as Dermatology Clinic of Idaho

  • Dermatology Physician
  • Boise, ID
National Provider Identifier
1548758501
Registry record updated Apr 25, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
Legal business name
MOUNTAIN WEST DERM-BLACKHART, PLLC
Doing business as
Dermatology Clinic of Idaho
Practice address
7733 W Emerald St
Boise, ID 83704-9020
Phone
(208) 939-4599
Fax
(208) 939-5010
NPI assigned
Apr 25, 2018
Last updated
Apr 25, 2018By the provider in NPPES
Organization subpart
Yes
Parent organization
MOUNTAIN WEST DERM-BLACKHART, PLLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Apr 25, 2018

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

Authorized official

Name
Bret S Blackhart, MDNPI 1992708655
Title
Owner
Phone
(775) 336-3624

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology Physician 207N00000X Primary

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 1

  • Dermatology Clinic of Idaho Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
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

Other NPIs with the same Medicare PAC ID 6

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Part of
MTN W Derm-Blackhart

Practitioners & affiliated clinicians

Practitioners 31

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 31

NPI Registry JSON

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

{
    "created_epoch": "1524614400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1524614400000",
    "number": "1548758501",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "201 FRANKLIN RD FL 3",
            "city": "BRENTWOOD",
            "state": "TN",
            "postal_code": "370275214",
            "telephone_number": "615-309-2636",
            "fax_number": "615-309-2536"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "7733 W EMERALD ST",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837049020",
            "telephone_number": "208-939-4599",
            "fax_number": "208-939-5010"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOUNTAIN WEST DERM-BLACKHART, PLLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MOUNTAIN WEST DERM-BLACKHART, PLLC",
        "enumeration_date": "2018-04-25",
        "last_updated": "2018-04-25",
        "status": "A",
        "authorized_official_last_name": "BLACKHART",
        "authorized_official_first_name": "BRET",
        "authorized_official_middle_name": "S",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "775-336-3624",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Dermatology Clinic of Idaho",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Boise, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 25, 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.