Provider Demographics
NPI:1548758501
Name:MOUNTAIN WEST DERM-BLACKHART, PLLC
Entity Type:Organization
Organization Name:MOUNTAIN WEST DERM-BLACKHART, PLLC
Other - Org Name:DERMATOLOGY CLINIC OF IDAHO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRET
Authorized Official - Middle Name:S
Authorized Official - Last Name:BLACKHART
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:775-336-3624
Mailing Address - Street 1:201 FRANKLIN RD FL 3
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5214
Mailing Address - Country:US
Mailing Address - Phone:615-309-2636
Mailing Address - Fax:615-309-2536
Practice Address - Street 1:7733 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9020
Practice Address - Country:US
Practice Address - Phone:208-939-4599
Practice Address - Fax:208-939-5010
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOUNTAIN WEST DERM-BLACKHART, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty