Healthcare Provider Details

I. General information

NPI: 1124061163
Provider Name (Legal Business Name): SUN VALLEY SPORTS MEDICINE, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 5TH ST W
KETCHUM ID
83340
US

IV. Provider business mailing address

191 5TH ST W
KETCHUM ID
83340
US

V. Phone/Fax

Practice location:
  • Phone: 208-726-5207
  • Fax: 208-726-8948
Mailing address:
  • Phone: 208-726-5207
  • Fax: 208-726-8948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN WASILWESKI
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 208-726-5207