Provider Demographics
NPI:1265547582
Name:HAYMORE, JEREMY B (MD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:B
Last Name:HAYMORE
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 1:1501 HILAND AVE
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2682
Mailing Address - Country:US
Mailing Address - Phone:208-677-6440
Mailing Address - Fax:208-677-6455
Practice Address - Street 1:1501 HILAND AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2682
Practice Address - Country:US
Practice Address - Phone:208-677-6440
Practice Address - Fax:208-677-6455
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062477A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200832230Medicaid
IN203170TTTMedicare PIN
INI69370Medicare UPIN