Provider Demographics
NPI:1811906076
Name:RONALD E JUTZY MD INC
Entity type:Organization
Organization Name:RONALD E JUTZY MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:E
Authorized Official - Last Name:JUTZY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-367-3500
Mailing Address - Street 1:6140 CURTISIAN AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8880
Mailing Address - Country:US
Mailing Address - Phone:208-367-3500
Mailing Address - Fax:208-367-2968
Practice Address - Street 1:6140 CURTISIAN AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8880
Practice Address - Country:US
Practice Address - Phone:208-367-3500
Practice Address - Fax:208-367-2968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5302207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806667900Medicaid
202662100OtherU S DEPARTMENT OF LABOR
ID72439OtherBLUE CROSS OF IDAHO
ID003530200Medicaid
ID8K321OtherBLUE CROSS OF IDAHO GROUP
OR190686OtherOMAP
WA12OtherWA DEPARTMENT OF LABOR
ID72439OtherBLUE CROSS OF IDAHO
A91337Medicare UPIN
1374120Medicare PIN