Provider Demographics
NPI:1922152024
Name:BLUE MOUNTAIN FOOT SPECIALISTS INC
Entity Type:Organization
Organization Name:BLUE MOUNTAIN FOOT SPECIALISTS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:F
Authorized Official - Last Name:BYRD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:541-276-2372
Mailing Address - Street 1:714 SW DORION AVE
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-2086
Mailing Address - Country:US
Mailing Address - Phone:541-276-2372
Mailing Address - Fax:
Practice Address - Street 1:714 SW DORION AVE
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-2086
Practice Address - Country:US
Practice Address - Phone:541-276-2372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00171213ES0103X, 332B00000X
ORDP00295213ES0103X, 332B00000X
ORDP00357213ES0103X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR480033064OtherRAILROAD MEDICARE
OR234444Medicaid
OR480026639OtherRAILROAD MEDICARE
OR162099Medicaid
ORCJ5600OtherRAILROAD MEDICARE
ORP00613653OtherRAILROAD MEDICARE
OR269055Medicaid
ORR102728Medicare PIN
ORU86797Medicare UPIN
OR480033064OtherRAILROAD MEDICARE
OR480026639OtherRAILROAD MEDICARE
OR269055Medicaid
ORT68292Medicare UPIN
OR1312600001Medicare NSC
ORR102729Medicare PIN