Basic Information
| Provider Information | |||||||||
| NPI: | 1447202726 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARDIOVASCULAR & CHEST SURGICAL ASSOCIATES, PA | ||||||||
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| OtherOrganizationName: | CARDIOTHORACIC & VASCULAR ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 N. 1ST ST. | ||||||||
| Address2: | #280 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083456545 | ||||||||
| FaxNumber: | 2083451213 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 N. 1ST ST. | ||||||||
| Address2: | #280 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083456545 | ||||||||
| FaxNumber: | 2083451213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HESGARD | ||||||||
| AuthorizedOfficialFirstName: | DONETTA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2083456545 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 2086S0129X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 363AS0400X | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 89508 | 01 | ID | BLUE CROSS | OTHER | 000010026913 | 01 | ID | BLUE SHIELD | OTHER | 049841 | 05 | OR | MEDICAID | CO3057 | 01 | ID | RRMC | OTHER |