Provider Demographics
NPI:1649385386
Name:RENCHER, MARK B (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:B
Last Name:RENCHER
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 1:1751 REVERE WAY
Mailing Address - Street 2:
Mailing Address - City:EAGLE MOUNTAIN
Mailing Address - State:UT
Mailing Address - Zip Code:84005-5147
Mailing Address - Country:US
Mailing Address - Phone:801-995-1951
Mailing Address - Fax:801-995-1951
Practice Address - Street 1:2610 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-523-0888
Practice Address - Fax:208-523-0968
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4486207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010000652OtherBLUE SHIELD
ID002543500Medicaid
ID44867OtherBLUE CROSS
ID002543500Medicaid
ID000010000652OtherBLUE SHIELD