Basic Information
| Provider Information | |||||||||
| NPI: | 1871016071 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PORTNEUF ASC, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 BURTON HILLS BLVD STE 250 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372156195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152963000 | ||||||||
| FaxNumber: | 6152966227 | ||||||||
| Practice Location | |||||||||
| Address1: | 1151 HOSPITAL WAY BLDG A | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832015091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082326616 | ||||||||
| FaxNumber: | 2082326618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2017 | ||||||||
| LastUpdateDate: | 07/19/2017 | ||||||||
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| AuthorizedOfficialLastName: | PETROVICH | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP | ||||||||
| AuthorizedOfficialTelephone: | 6152963000 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | POCATELLO HEALTH SYSTEM, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.