Provider Demographics
NPI:1073757464
Name:MICHAEL R DIBENEDETTO MD PLLC
Entity Type:Organization
Organization Name:MICHAEL R DIBENEDETTO MD PLLC
Other - Org Name:SEASONS PLASTIC & RECONSTRUCTIVE SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:S
Authorized Official - Last Name:BROSNAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-263-5900
Mailing Address - Street 1:30544 HIGHWAY 200
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PONDERAY
Mailing Address - State:ID
Mailing Address - Zip Code:83852-5005
Mailing Address - Country:US
Mailing Address - Phone:208-263-5900
Mailing Address - Fax:208-263-1319
Practice Address - Street 1:30544 HIGHWAY 200
Practice Address - Street 2:SUITE 102
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852-5005
Practice Address - Country:US
Practice Address - Phone:208-263-5900
Practice Address - Fax:208-263-1319
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MICHAEL R DIBENEDETTO MD PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-29
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM106712086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDDG3627OtherRAIL ROAD MEDICARE
ID8N834OtherBLUE CROSS
IDDG3627OtherRAIL ROAD MEDICARE