MEDICARE: BOISE SHOULDER CLINIC, PA

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	207X00000X	Orthopaedic Surgery Physician	M9563	ID

General Provider Information

NPI Number	:	1760581409
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOISE SHOULDER CLINIC, PA

Provider Business Mailing Address
First Line	:	3381 W BAVARIA STREET
Second Line	:
City	:	EAGLE
State	:	ID
Zip	:	83616-5341
Country	:	US
Telephone Number	:	208-639-4800
Fax Number	:	208-639-4801

Provider Business Practice Location Address
First Line	:	3381 W BAVARIA STREET
Second Line	:
City	:	EAGLE
State	:	ID
Zip	:	83616-5341
Country	:	US
Telephone Number	:	208-639-4800
Fax Number	:	208-639-4801

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CARL SCOTT HUMPHREY
Credential	:	MD
Telephone Number	:	208-639-4800

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	02/13/2012

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