Provider Demographics
NPI:1194762815
Name:PEAK MEDICAL OF BOISE LLC
Entity type:Organization
Organization Name:PEAK MEDICAL OF BOISE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4752
Mailing Address - Street 1:8211 W USTICK RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5756
Mailing Address - Country:US
Mailing Address - Phone:208-375-3700
Mailing Address - Fax:208-375-3760
Practice Address - Street 1:8211 W USTICK RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5756
Practice Address - Country:US
Practice Address - Phone:208-375-3700
Practice Address - Fax:208-375-3760
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEAK MEDICAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-01
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID47314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010136091OtherBLUE SHIELD OF IDAHO
ID04036OtherBLUE CROSS
ID805350300Medicaid
ID04036OtherBLUE CROSS