Provider Demographics
NPI:1053493809
Name:DJ MARC CARDINAL, MD PA
Entity Type:Organization
Organization Name:DJ MARC CARDINAL, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DJ
Authorized Official - Middle Name:MARC
Authorized Official - Last Name:CARDINAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-785-3810
Mailing Address - Street 1:PO BOX 2896
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-2896
Mailing Address - Country:US
Mailing Address - Phone:208-523-4906
Mailing Address - Fax:208-523-2025
Practice Address - Street 1:98 POPLAR ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1758
Practice Address - Country:US
Practice Address - Phone:208-785-3810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DG2308OtherRAILROAD MEDICARE GROUP
ID806651100Medicaid
ID1374836Medicare PIN