1992759930 NPI number — IDAHO SURGICENTER INC

Table of content: (NPI 1992759930)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992759930 NPI number — IDAHO SURGICENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IDAHO SURGICENTER INC
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:
6
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:
1992759930
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2067
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POCATELLO
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83206-2067
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-238-6337
Provider Business Mailing Address Fax Number:
208-776-5510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1157 CALL PLACE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-238-6337
Provider Business Practice Location Address Fax Number:
208-776-5510
Provider Enumeration Date:
05/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BARNARD
Authorized Official First Name:
SEAN
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
208-852-6242

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  P166 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X , with the licence number: P92 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X , with the licence number: P153 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 000010027108 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 805730900 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00091636 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 03913 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 807288200 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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