Basic Information
| Provider Information | |||||||||
| NPI: | 1669410361 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SNAKE RIVER GASTROENTEROLOGY LABS, L.L.C. | ||||||||
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| OtherOrganizationName: | SNAKE RIVER ENDOSCOPY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 141 MORRISON ST | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833015451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087323030 | ||||||||
| FaxNumber: | 2087338970 | ||||||||
| Practice Location | |||||||||
| Address1: | 141 MORRISON ST | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833015451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087323030 | ||||||||
| FaxNumber: | 2087338970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 06/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | WARD | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 2087323030 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
ID Information
| ID | Type | State | Issuer | Description | 806686500 | 05 | ID | MEDICAID | P00056475 | 01 | ID | RR MEDICARE | OTHER |