Healthcare Provider Details

I. General information

NPI: 1730300054
Provider Name (Legal Business Name): JSC ANESTHESIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 E 17TH ST
IDAHO FALLS ID
83404-6313
US

IV. Provider business mailing address

650 ADDISON AVE W
TWIN FALLS ID
83301-5444
US

V. Phone/Fax

Practice location:
  • Phone: 208-525-2090
  • Fax: 208-525-2662
Mailing address:
  • Phone: 208-525-2090
  • Fax: 208-525-2662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberN22808
License Number StateID

VIII. Authorized Official

Name: JOHN CARMICHAEL
Title or Position: OWNER
Credential: CRNA
Phone: 208-525-2090