Basic Information
| Provider Information | |||||||||
| NPI: | 1750386256 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PALOUSE SURGERY CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 W A ST | ||||||||
| Address2: | |||||||||
| City: | MOSCOW | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838434038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088831500 | ||||||||
| FaxNumber: | 2088827701 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 W A ST | ||||||||
| Address2: | |||||||||
| City: | MOSCOW | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838434038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088831500 | ||||||||
| FaxNumber: | 2088827701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| LastUpdateDate: | 03/20/2012 | ||||||||
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| AuthorizedOfficialLastName: | DECKER | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2088831500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | ID | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 806919900 | 05 | ID | MEDICAID | 1870569 | 01 | ID | MEDICARE PTAN | OTHER |