Healthcare Provider Details

I. General information

NPI: 1760581409
Provider Name (Legal Business Name): BOISE SHOULDER CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 02/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3381 W BAVARIA STREET
EAGLE ID
83616-5341
US

IV. Provider business mailing address

3381 W BAVARIA STREET
EAGLE ID
83616-5341
US

V. Phone/Fax

Practice location:
  • Phone: 208-639-4800
  • Fax: 208-639-4801
Mailing address:
  • Phone: 208-639-4800
  • Fax: 208-639-4801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberM9563
License Number StateID

VIII. Authorized Official

Name: DR. CARL SCOTT HUMPHREY
Title or Position: OWNER
Credential: MD
Phone: 208-639-4800