Provider Demographics
NPI:1306917000
Name:MEDICAL SURGICAL GROUP INC
Entity type:Organization
Organization Name:MEDICAL SURGICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:HOFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-743-0962
Mailing Address - Street 1:307 SAINT JOHNS WAY
Mailing Address - Street 2:SUITE 6
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2435
Mailing Address - Country:US
Mailing Address - Phone:208-743-0962
Mailing Address - Fax:
Practice Address - Street 1:307 SAINT JOHNS WAY
Practice Address - Street 2:SUITE 6
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2435
Practice Address - Country:US
Practice Address - Phone:208-743-0962
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID164590261QR0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010005483OtherREGENCE
ID8987-0OtherBLUE CROSS OF IDAHO
WA7025844Medicaid
WA7025844Medicaid