Healthcare Provider Details

I. General information

NPI: 1497768626
Provider Name (Legal Business Name): IDAHO FOOT SURGERY CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 ELK CREEK DR.
IDAHO FALLS ID
83404
US

IV. Provider business mailing address

1540 ELK CREEK DR.
IDAHO FALLS ID
83404
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-8393
  • Fax:
Mailing address:
  • Phone: 208-529-8393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number1870101
License Number StateID

VIII. Authorized Official

Name: DR. BRUCE G TOLMAN
Title or Position: OWNER
Credential: DPM
Phone: 208-529-8393