Provider Demographics
NPI:1659365575
Name:BLUE, SKY R (MD)
Entity Type:Individual
Prefix:
First Name:SKY
Middle Name:R
Last Name:BLUE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 E IDAHO ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6212
Mailing Address - Country:US
Mailing Address - Phone:208-338-0148
Mailing Address - Fax:208-336-4027
Practice Address - Street 1:125 E IDAHO ST
Practice Address - Street 2:SUITE 203
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6212
Practice Address - Country:US
Practice Address - Phone:208-338-0148
Practice Address - Fax:208-336-4027
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM7398207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010000484OtherREGENCE BLUE SHIELD OF ID
IDJ1676OtherBLUE CROSS OF IDAHO
IDG16995Medicare UPIN
ID1138504Medicare ID - Type Unspecified