Provider Demographics
NPI:1194735522
Name:IDAHO SURGICENTER NORTH LLC
Entity type:Organization
Organization Name:IDAHO SURGICENTER NORTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:D
Authorized Official - Last Name:QUINTON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:208-529-0009
Mailing Address - Street 1:PO BOX 1386
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-1386
Mailing Address - Country:US
Mailing Address - Phone:208-529-0009
Mailing Address - Fax:208-529-2252
Practice Address - Street 1:3369 MERLIN DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7405
Practice Address - Country:US
Practice Address - Phone:208-529-0009
Practice Address - Fax:208-529-2252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP 186261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI000010027109OtherBLUE SHIELD
ID04085OtherBLUE CROSS
ID1870500Medicare ID - Type Unspecified