1831134584 NPI number — REXBURG SURGERY CENTER LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831134584 NPI number — REXBURG SURGERY CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REXBURG SURGERY CENTER LLC
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:
NORTH FORK 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:
1831134584
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
381 EAST 4TH NORTH
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
REXBURG
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83440
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-359-2300
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
381 EAST 4TH NORTH
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
REXBURG
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-359-2300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HANSEN
Authorized Official First Name:
DWAYNE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
BOARD CHAIRMAN
Authorized Official Telephone Number:
208-359-2300

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , 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: 000010158869 . This is a "BLUE SHIELD PROVIDER NUMB" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 04870 . This is a "BLUE CROSS PROVIDER NUMBE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 80760000 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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