Provider Demographics
NPI:1962691204
Name:IDAHO NEUROLOGICAL SURGERY, P.A.
Entity type:Organization
Organization Name:IDAHO NEUROLOGICAL SURGERY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER/NEUROSURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:208-344-1000
Mailing Address - Street 1:222 N. 2ND STREET
Mailing Address - Street 2:SUITE 307
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6131
Mailing Address - Country:US
Mailing Address - Phone:208-344-1000
Mailing Address - Fax:208-344-1331
Practice Address - Street 1:222 N. 2ND STREET
Practice Address - Street 2:SUITE 307
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6131
Practice Address - Country:US
Practice Address - Phone:208-344-1000
Practice Address - Fax:208-344-1331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-3522174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002755500Medicaid
ID002755500Medicaid