Basic Information
Provider Information | |||||||||
NPI: | 1972179208 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | IDAHO OTOLOGIC SURGERY CENTER, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SYRINGA OUTPATIENT SURGERY CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13900 W WAINWRIGHT DR STE 102 | ||||||||
Address2: |   | ||||||||
City: | BOISE | ||||||||
State: | ID | ||||||||
PostalCode: | 837135028 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4804552769 | ||||||||
FaxNumber: | 2089633270 | ||||||||
Practice Location | |||||||||
Address1: | 1209 N SUMMERBROOK AVE STE 110 | ||||||||
Address2: |   | ||||||||
City: | MERIDIAN | ||||||||
State: | ID | ||||||||
PostalCode: | 836428760 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2089385823 | ||||||||
FaxNumber: | 2089633270 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/27/2021 | ||||||||
LastUpdateDate: | 10/06/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CRAWFORD | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 2532784304 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 10/06/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.