Organization
MICHAEL R DIBENEDETTO MD PLLC
Active
Parent organization
MICHAEL R DIBENEDETTO MD PLLC
Other names
Seasons Plastic & Reconstructive Surgery
Organization subpart
Yes
Provider details
NPI number
Legal business name
MICHAEL R DIBENEDETTO MD PLLC
Authorized official
WENDY S BROSNAHAN (OFFICE MANAGER)
(208) 263-5900
Entity
Organization
Contact information
Practice address
30544 HIGHWAY 200, SUITE 102, PONDERAY, ID 83852-5005
(208) 263-5900
(208) 263-1319
Mailing address
30544 HIGHWAY 200, SUITE 102, PONDERAY, ID 83852-5005
(208) 263-5900
(208) 263-1319
Taxonomy
Speciality
Code
Description
License number
State
2086S0122X
Plastic and Reconstructive Surgery Physician
Primary
M10671
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
8N834
BLUE CROSS
ID
01
—
DG3627
RAIL ROAD MEDICARE
ID
Enumeration date
04/29/2009
Last updated
10/21/2009
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