Provider Demographics
NPI:1013137850
Name:MORGAN, MARK (PT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MORGAN
Suffix:
Gender:M
Credentials:PT
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 1191
Mailing Address - Street 2:
Mailing Address - City:HAILEY
Mailing Address - State:ID
Mailing Address - Zip Code:83333-1191
Mailing Address - Country:US
Mailing Address - Phone:208-788-0061
Mailing Address - Fax:208-788-2211
Practice Address - Street 1:221 S RIVER ST
Practice Address - Street 2:
Practice Address - City:HAILEY
Practice Address - State:ID
Practice Address - Zip Code:83333-8436
Practice Address - Country:US
Practice Address - Phone:208-788-0061
Practice Address - Fax:208-788-2211
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2011-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-6472251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010025485OtherBLUE SHIELD PROVIDER NUM.
ID805397000Medicaid
IDT6251OtherBLUE CROSS PROVIDER NUM.
IDP00060576OtherRAILROAD MEDICARE NUMBER
ID1652293Medicare ID - Type UnspecifiedPROVIDER NUMBER