Mountain Crest Foot and Ankle PA

Primary specialty

PodiatristTaxonomy code 213E00000X

License

P-169 Issued in ID

Legal business name

MOUNTAIN CREST FOOT AND ANKLE PA

Practice address

3652 Washington Pkwy
Idaho Falls, ID 83404-7573

Phone

(208) 528-8700

Fax

(208) 528-2802

NPI assigned

Aug 16, 2005

Organization subpart

No

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

Authorized official

Name

Dr. Timothy Roger Black, DPMNPI 1578753091

Title

Owner/Physician

Phone

(208) 528-8700

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in ID

Enrollment records 1

Locations

Practitioners 1

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

• Timothy Roger Black, DPM

  • Podiatrist
  • Idaho Falls, ID
  • NPI 1578753091
  Medicare reassignment NPD Authorized official

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

{
    "created_epoch": "1124150400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1291593600000",
    "number": "1932191996",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3652 WASHINGTON PKWY",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834047573",
            "telephone_number": "208-528-8700",
            "fax_number": "208-528-2802"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3652 WASHINGTON PKWY",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834047573",
            "telephone_number": "208-528-8700",
            "fax_number": "208-528-2802"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOUNTAIN CREST FOOT AND ANKLE PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-08-16",
        "last_updated": "2010-12-06",
        "status": "A",
        "authorized_official_last_name": "BLACK",
        "authorized_official_first_name": "TIMOTHY",
        "authorized_official_middle_name": "ROGER",
        "authorized_official_title_or_position": "OWNER/PHYSICIAN",
        "authorized_official_telephone_number": "208-528-8700",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DPM"
    },
    "taxonomies": [
        {
            "code": "213E00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Podiatrist",
            "state": "ID",
            "license": "P-169",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "806462800",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Sheila Moss, FNP-C
• Moulton Periodontics, PLLC
• Barbara J Moulton
• Ethan D. Moulton, D.D.S.,M.S.
• Mountain Care Pharmacy Idaho
• Mountain Falls Medical LLC
• Mountain Falls Quick Care
• Mountain River Mental Health
• Mountain River Mental Health
• Mountain States Cardiovascular and

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

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 6, 2010; 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.