Healthcare Provider Details

I. General information

NPI: 1306917000
Provider Name (Legal Business Name): MEDICAL SURGICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 SAINT JOHNS WAY SUITE 6
LEWISTON ID
83501-2435
US

IV. Provider business mailing address

307 SAINT JOHNS WAY SUITE 6
LEWISTON ID
83501-2435
US

V. Phone/Fax

Practice location:
  • Phone: 208-743-0962
  • Fax:
Mailing address:
  • Phone: 208-743-0962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number164590
License Number StateID

VIII. Authorized Official

Name: MICHAEL JOHN HOFFMAN
Title or Position: BUSINESS MANAGER
Credential:
Phone: 208-743-0962