Provider Demographics
NPI:1093753360
Name:ROONEY, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:ROONEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 816
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-0816
Mailing Address - Country:US
Mailing Address - Phone:208-743-2511
Mailing Address - Fax:208-799-5528
Practice Address - Street 1:415 6TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2431
Practice Address - Country:US
Practice Address - Phone:208-743-2511
Practice Address - Fax:208-799-5528
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-4745207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002649400Medicaid
IDHB112OtherBLUE CROSS OF IDAHO
ID10004623OtherREGENCE OF IDAHO
WA8616708Medicaid
ID002649400Medicaid
ID10004623OtherREGENCE OF IDAHO