MEDICARE: IDAHO FALLS SURCIGAL CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center	13-C0001000	ID

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	490000095	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053481218
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDAHO FALLS SURCIGAL CENTER

Provider Business Mailing Address
First Line	:	PO BOX 52180
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83405-2180
Country	:	US
Telephone Number	:	208-523-4906
Fax Number	:	208-523-2025

Provider Business Practice Location Address
First Line	:	1945 E 17TH ST
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-6429
Country	:	US
Telephone Number	:	208-529-1945
Fax Number	:	208-529-1961

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MARK L PETERSEN
Credential	:	MD
Telephone Number	:	208-529-1945

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	06/09/2008

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