Healthcare Provider Details

I. General information

NPI: 1992070809
Provider Name (Legal Business Name): PAIN SPECIALISTS OF IDAHO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2012
Last Update Date: 03/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2375 E SUNNYSIDE RD STE J
IDAHO FALLS ID
83404-8281
US

IV. Provider business mailing address

2375 E SUNNYSIDE RD STE J
IDAHO FALLS ID
83404-8281
US

V. Phone/Fax

Practice location:
  • Phone: 208-522-7246
  • Fax: 208-529-2620
Mailing address:
  • Phone: 208-522-7246
  • Fax: 208-529-2620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberSPHY11061
License Number StateID

VIII. Authorized Official

Name: CORI D ANDERSON
Title or Position: BILLING MANAGER
Credential:
Phone: 208-522-7246