Healthcare Provider Details

I. General information

NPI: 1376858878
Provider Name (Legal Business Name): EAST FALLS CARDIOVASCULAR AND THORACIC SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2010
Last Update Date: 08/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2860 CHANNING WAY STE 112
IDAHO FALLS ID
83404-7532
US

IV. Provider business mailing address

2860 CHANNING WAY STE 112
IDAHO FALLS ID
83404-7531
US

V. Phone/Fax

Practice location:
  • Phone: 208-535-4566
  • Fax:
Mailing address:
  • Phone: 208-535-4566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number StateID

VIII. Authorized Official

Name: MR. DAVID J KANE
Title or Position: VICE PRESIDENT OF OPERATIONS
Credential:
Phone: 801-568-5936