Provider Demographics
NPI:1932224813
Name:BLEFFERT, MICHAEL P (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:BLEFFERT
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 1:600 VALLEY CENTRE DRIVE
Mailing Address - Street 2:
Mailing Address - City:DRIGGS
Mailing Address - State:ID
Mailing Address - Zip Code:83422
Mailing Address - Country:US
Mailing Address - Phone:208-354-0089
Mailing Address - Fax:509-561-0536
Practice Address - Street 1:600 VALLEY CENTRE DRIVE
Practice Address - Street 2:
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422
Practice Address - Country:US
Practice Address - Phone:208-354-0089
Practice Address - Fax:509-561-0536
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1337225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805912700Medicaid
ID805912700Medicaid