Provider Demographics
NPI:1598817348
Name:IDAHO SURGICAL PARTNERS, PC
Entity type:Organization
Organization Name:IDAHO SURGICAL PARTNERS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMI
Authorized Official - Middle Name:
Authorized Official - Last Name:YANTIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-649-8347
Mailing Address - Street 1:PO BOX 2045
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-9110
Mailing Address - Country:US
Mailing Address - Phone:208-343-5600
Mailing Address - Fax:208-779-2889
Practice Address - Street 1:323 E RIVERSIDE DR STE 220
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-5246
Practice Address - Country:US
Practice Address - Phone:208-343-5600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6834174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002779400Medicaid
ID807305800Medicaid
IDG08726Medicare UPIN
ID1667251Medicare ID - Type UnspecifiedKAROLINE CASEY DEMPSEY