Basic Information
Provider Information | |||||||||
NPI: | 1992789564 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ADER | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | T. | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO-RHEUMATOLOGY | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 215 E HAWAII AVE | ||||||||
Address2: |   | ||||||||
City: | NAMPA | ||||||||
State: | ID | ||||||||
PostalCode: | 836866011 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2084633000 | ||||||||
FaxNumber: | 2084633044 | ||||||||
Practice Location | |||||||||
Address1: | 3277 E LOUISE DR | ||||||||
Address2: | SUITE 200 | ||||||||
City: | MERIDIAN | ||||||||
State: | ID | ||||||||
PostalCode: | 836429359 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2088842920 | ||||||||
FaxNumber: | 2084633044 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/06/2005 | ||||||||
LastUpdateDate: | 12/09/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | M9114 | TX | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207R00000X | M9114 | TX | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RR0500X | O-0634 | ID | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
ID | Type | State | Issuer | Description | 1992789564 | 05 | ID |   | MEDICAID | 4517667 | 05 | MI |   | MEDICAID |