Individual
MICHAEL RAYMOND DIBENEDETTO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
30544 HIGHWAY 200, STE 102, PONDERAY, ID 83852-5005
(208) 265-9817
(208) 265-4533
Mailing address
30544 HIGHWAY 200, STE 102, PONDERAY, ID 83852-5005
(208) 265-9817
(208) 265-4533
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
Primary
M8578
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010140056
REGENCE
ID
01
—
77010
BLUE CROSS
ID
05
—
806452000
—
ID
01
—
P00042698
PALMETTOGBA RAILROAD MEDI
ID
Enumeration date
11/13/2006
Last updated
04/03/2013
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