1770598591 NPI number — BOISE CENTER FOR FOOT SURGERY PLLC

Table of content: (NPI 1770598591)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770598591 NPI number — BOISE CENTER FOR FOOT SURGERY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOISE CENTER FOR FOOT SURGERY PLLC
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:
MILLENNIUM SURGERY CENTER
Provider Other Organization Name Type Code:
3
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:
1770598591
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1828 MILLENIUM WAY
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83642-5036
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-381-0262
Provider Business Mailing Address Fax Number:
208-429-8575

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1828 S MILLENNIUM WAY
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-5036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-381-0262
Provider Business Practice Location Address Fax Number:
208-429-8575
Provider Enumeration Date:
07/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MILLWARD
Authorized Official First Name:
GARY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
208-381-0262

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  13C0001011 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 002761500 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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