Provider Demographics
NPI:1487746541
Name:ORTHOPEDIC CENTERS OF IDAHO P A
Entity type:Organization
Organization Name:ORTHOPEDIC CENTERS OF IDAHO P A
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:KNIEFEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-323-2600
Mailing Address - Street 1:1075 N CURTIS RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-1300
Mailing Address - Country:US
Mailing Address - Phone:208-323-2600
Mailing Address - Fax:
Practice Address - Street 1:1075 N CURTIS RD
Practice Address - Street 2:SUITE 300
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1348
Practice Address - Country:US
Practice Address - Phone:208-323-2600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CB3819Medicare PIN
1377324Medicare PIN
ID4036070002Medicare NSC