Provider Demographics
NPI:1992759930
Name:IDAHO SURGICENTER INC
Entity type:Organization
Organization Name:IDAHO SURGICENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BARNARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-852-6242
Mailing Address - Street 1:PO BOX 2067
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83206-2067
Mailing Address - Country:US
Mailing Address - Phone:208-238-6337
Mailing Address - Fax:208-776-5510
Practice Address - Street 1:1157 CALL PLACE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-238-6337
Practice Address - Fax:208-776-5510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP166213ES0103X
IDP92213ES0103X
IDP153213ES0103X
261QA1903X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010027108OtherBLUE SHIELD
ID805730900Medicaid
IDP00091636OtherRAILROAD MEDICARE
ID03913OtherBLUE CROSS
ID807288200Medicaid