Healthcare Provider Details

I. General information

NPI: 1376607309
Provider Name (Legal Business Name): EMERALD SURGICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 N LIBERTY ST
BOISE ID
83704-8703
US

IV. Provider business mailing address

811 N LIBERTY ST
BOISE ID
83704-8703
US

V. Phone/Fax

Practice location:
  • Phone: 208-323-4522
  • Fax:
Mailing address:
  • Phone: 208-323-4522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. KERRY W. ANDERSON
Title or Position: MGN. PARTNER
Credential: DPM
Phone: 208-323-4522