Provider Demographics
NPI:1083809727
Name:MICHAEL R DIBENEDETTO MD PLLC
Entity Type:Organization
Organization Name:MICHAEL R DIBENEDETTO MD PLLC
Other - Org Name:NORTH IDAHO ORTHOPEDICS & SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:GARMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-265-9817
Mailing Address - Street 1:30544 HWY 200
Mailing Address - Street 2:STE 102
Mailing Address - City:PONDERAY
Mailing Address - State:ID
Mailing Address - Zip Code:83852
Mailing Address - Country:US
Mailing Address - Phone:208-265-9817
Mailing Address - Fax:208-263-7249
Practice Address - Street 1:30544 HWY 200
Practice Address - Street 2:STE 102
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852
Practice Address - Country:US
Practice Address - Phone:208-265-9836
Practice Address - Fax:208-263-7249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No261QR0404XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Cardiac FacilitiesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDDG3627OtherPALMETTO GBA RAILROAD MED
ID806452000Medicaid
ID000010140056OtherREGENCE BLUE SHIELD
ID8N259OtherBLUE CROSS
IDDG3627OtherPALMETTO GBA RAILROAD MED
ID806452000Medicaid
ID5302280001Medicare NSC