Basic Information
| Provider Information | |||||||||
| NPI: | 1760487771 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SINUS CENTER - IDAHO, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 727 E RIVERPARK LN | ||||||||
| Address2: | STE 200 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837064097 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084339300 | ||||||||
| FaxNumber: | 2084339854 | ||||||||
| Practice Location | |||||||||
| Address1: | 727 E RIVERPARK LN | ||||||||
| Address2: | STE 200 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837064097 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084339300 | ||||||||
| FaxNumber: | 2084339854 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BOYAJIAN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2084339300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Legal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8069720000 | 05 | ID | MEDICAID |