Basic Information
Provider Information
NPI: 1003805037
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: TERRY
FirstName: BEN
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: DO
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 217 W GEORGIA AVE
Address2: SUITE 115
City: NAMPA
State: ID
PostalCode: 836866811
CountryCode: US
TelephoneNumber: 2084633000
FaxNumber: 2084633034
Practice Location
Address1: 4400 E FLAMINGO AVE
Address2:  
City: NAMPA
State: ID
PostalCode: 836879203
CountryCode: US
TelephoneNumber: 2082884970
FaxNumber: 2082884990
Other Information
ProviderEnumerationDate: 10/21/2005
LastUpdateDate: 07/13/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000XO-225IDY Allopathic & Osteopathic PhysiciansFamily Medicine 

ID Information
IDTypeStateIssuerDescription
S311901IDBLUE CROSSOTHER
00001002747401IDBLUE CROSSOTHER
00001002747301IDBLUE CROSSOTHER
S310101IDBLUE CROSSOTHER
0814820901IDRAILROAD MEDICAREOTHER


Home