Healthcare Provider Details

I. General information

NPI: 1295908127
Provider Name (Legal Business Name): IDAHO SKIN SURGERY CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2008
Last Update Date: 12/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 S VISTA AVE
BOISE ID
83705-3453
US

IV. Provider business mailing address

1906 S VISTA AVE
BOISE ID
83705-3453
US

V. Phone/Fax

Practice location:
  • Phone: 208-433-1114
  • Fax: 208-433-1115
Mailing address:
  • Phone: 208-433-1114
  • Fax: 208-433-1115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberM-10116
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberM-10116
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberM-10116
License Number StateID

VIII. Authorized Official

Name: JARED SCOTT
Title or Position: PRESIDENT
Credential: MD
Phone: 208-433-1114