1609983089 NPI number — INTERMOUNTAIN SURGERY CENTER

Table of content: (NPI 1609983089)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609983089 NPI number — INTERMOUNTAIN SURGERY CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERMOUNTAIN SURGERY CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609983089
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 ROBBINS RD
Provider Second Line Business Mailing Address:
STE 401
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83702-4539
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-383-0201
Provider Business Mailing Address Fax Number:
208-489-4300

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 N ROBBINS RD
Provider Second Line Business Practice Location Address:
STE 401
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-383-0201
Provider Business Practice Location Address Fax Number:
208-489-4010
Provider Enumeration Date:
08/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BARNHART
Authorized Official First Name:
BRANDI
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING COORDINATOR
Authorized Official Telephone Number:
208-489-4206

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 490005004 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 04077 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 185507800 . This is a "US DEPT OF LABOR" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010028431 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 805845600 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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