Healthcare Provider Details

I. General information

NPI: 1700827946
Provider Name (Legal Business Name): STEPHEN A WASILEWSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 09/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 5TH STREET WEST
KETCHUM ID
83340
US

IV. Provider business mailing address

PO BOX 587
TWIN FALLS ID
83303-0587
US

V. Phone/Fax

Practice location:
  • Phone: 208-726-5207
  • Fax: 208-726-8948
Mailing address:
  • Phone: 208-814-7400
  • Fax: 208-814-7491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberM5774
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: