Provider Demographics
NPI:1326088626
Name:KNOEBEL, RICHARD T (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:T
Last Name:KNOEBEL
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 2920
Mailing Address - Street 2:
Mailing Address - City:HAILEY
Mailing Address - State:ID
Mailing Address - Zip Code:83333-2920
Mailing Address - Country:US
Mailing Address - Phone:208-788-3889
Mailing Address - Fax:
Practice Address - Street 1:400 S MAIN ST
Practice Address - Street 2:STE 203
Practice Address - City:HAILEY
Practice Address - State:ID
Practice Address - Zip Code:83333-8402
Practice Address - Country:US
Practice Address - Phone:208-788-3889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM57695207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
E57918Medicare UPIN