Basic Information
| Provider Information | |||||||||
| NPI: | 1740479476 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEADOW LAKE SURGERY CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3630 E LOUISE DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836427975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083779515 | ||||||||
| FaxNumber: | 2083779517 | ||||||||
| Practice Location | |||||||||
| Address1: | 3630 E LOUISE DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836427975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083779515 | ||||||||
| FaxNumber: | 2083779517 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2007 | ||||||||
| LastUpdateDate: | 09/16/2013 | ||||||||
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| AuthorizedOfficialLastName: | WIGOD | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | M.D. | ||||||||
| AuthorizedOfficialTelephone: | 2083779515 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | M8189 | ID | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.