Provider Demographics
NPI:1194787010
Name:MAGIC VALLEY REGIONAL MEDICAL CENTER
Entity type:Organization
Organization Name:MAGIC VALLEY REGIONAL MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:PERIUS
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:208-737-2112
Mailing Address - Street 1:2519 E 2519 N
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301
Mailing Address - Country:US
Mailing Address - Phone:208-735-1628
Mailing Address - Fax:
Practice Address - Street 1:650 ADDISON AVE W
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5444
Practice Address - Country:US
Practice Address - Phone:208-737-2112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA 258282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital