Provider Demographics
NPI:1386614519
Name:IDAHO SURGERY CENTER, LLC
Entity type:Organization
Organization Name:IDAHO SURGERY CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOGUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-453-8668
Mailing Address - Street 1:3115 MEDICAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-6972
Mailing Address - Country:US
Mailing Address - Phone:208-453-8668
Mailing Address - Fax:208-453-8448
Practice Address - Street 1:3115 MEDICAL DRIVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-6972
Practice Address - Country:US
Practice Address - Phone:208-453-8668
Practice Address - Fax:208-453-8448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-23
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807417200Medicaid
1870660Medicare PIN