Provider Demographics
NPI:1215238795
Name:SYNERGY PAIN MANAGEMENT AND REHABILITATION
Entity type:Organization
Organization Name:SYNERGY PAIN MANAGEMENT AND REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:OSTLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-229-7075
Mailing Address - Street 1:PO BOX 434
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-0434
Mailing Address - Country:US
Mailing Address - Phone:208-229-7075
Mailing Address - Fax:208-229-7076
Practice Address - Street 1:875 E PLAZA DR
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6548
Practice Address - Country:US
Practice Address - Phone:208-229-7075
Practice Address - Fax:208-229-7076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-15
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty