Provider Demographics
NPI:1184812232
Name:WAYNE H BLAUER MD PA
Entity type:Organization
Organization Name:WAYNE H BLAUER MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:H
Authorized Official - Last Name:BLAUER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-678-2283
Mailing Address - Street 1:1501 HILAND AVE
Mailing Address - Street 2:STE L3
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2682
Mailing Address - Country:US
Mailing Address - Phone:208-678-2283
Mailing Address - Fax:208-677-2483
Practice Address - Street 1:1501 HILAND AVE
Practice Address - Street 2:STE L3
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2682
Practice Address - Country:US
Practice Address - Phone:208-678-2283
Practice Address - Fax:208-677-2483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-12
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-4491207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC-36926Medicare UPIN
ID1376577Medicare PIN