Provider Demographics
NPI:1124061163
Name:SUN VALLEY SPORTS MEDICINE, P.A.
Entity type:Organization
Organization Name:SUN VALLEY SPORTS MEDICINE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WASILWESKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-726-5207
Mailing Address - Street 1:191 5TH ST W
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340
Mailing Address - Country:US
Mailing Address - Phone:208-726-5207
Mailing Address - Fax:208-726-8948
Practice Address - Street 1:191 5TH ST W
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340
Practice Address - Country:US
Practice Address - Phone:208-726-5207
Practice Address - Fax:208-726-8948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID200015728OtherRR MEDICARE
ID805960600Medicaid
ID1374830Medicare ID - Type UnspecifiedMEDICARE NUMBER
ID805960600Medicaid