Basic Information
| Provider Information | |||||||||
| NPI: | 1215145883 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALTENBURG | ||||||||
| FirstName: | AARON | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 285 VISTA DRIVE | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082338344 | ||||||||
| FaxNumber: | 2082336983 | ||||||||
| Practice Location | |||||||||
| Address1: | 285 VISTA DRIVE | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082338344 | ||||||||
| FaxNumber: | 2082336983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 03/01/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | R-6902 | IA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 49915 | MN | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 432482100 | 05 | MN | MEDICAID |