Basic Information
| Provider Information | |||||||||
| NPI: | 1114923471 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SURGICARE CENTER OF IDAHO, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 360 E MALLARD DR | ||||||||
| Address2: | STE 125 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837066644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083368700 | ||||||||
| FaxNumber: | 2084260902 | ||||||||
| Practice Location | |||||||||
| Address1: | 360 E MALLARD DR | ||||||||
| Address2: | STE 125 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837063941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083368700 | ||||||||
| FaxNumber: | 2084260902 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 10/10/2016 | ||||||||
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| AuthorizedOfficialLastName: | PENNOW | ||||||||
| AuthorizedOfficialFirstName: | LOUIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2083368700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS0132X | N | Ambulatory Health Care Facilities | Clinic/Center | Ophthalmologic Surgery | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 273390 | 05 | ID | MEDICAID |