MEDICARE: MCKIM SURGERY CENTER, INC

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	M7009	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000010147715	OTHER	ID	BLUE SHIELD
2	04366	OTHER	ID	BLUE CROSS OF IDAHO

General Provider Information

NPI Number	:	1134236433
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MCKIM SURGERY CENTER, INC

Provider Business Mailing Address
First Line	:	900 N LIBERTY ST STE 300
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83704-8729
Country	:	US
Telephone Number	:	208-367-6901
Fax Number	:	208-367-6904

Provider Business Practice Location Address
First Line	:	900 N LIBERTY ST STE 300
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83704-8729
Country	:	US
Telephone Number	:	208-367-6901
Fax Number	:	208-367-6904

Authorized Official
Title or Position	:	OWNER
Name	:	DR. THOMAS D MCKIM
Credential	:	M.D.
Telephone Number	:	208-367-6901

Provider Enumeration Date	:	08/23/2006
Last Update Date	:	08/22/2020

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