Healthcare Provider Details

I. General information

NPI: 1871648352
Provider Name (Legal Business Name): BOISE SURGICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 06/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3399 E. LOUISE DR. #400
MERIDIAN ID
83642
US

IV. Provider business mailing address

3399 E. LOUISE DR. #400
MERIDIAN ID
83642
US

V. Phone/Fax

Practice location:
  • Phone: 208-364-3000
  • Fax: 208-364-3191
Mailing address:
  • Phone: 208-364-3000
  • Fax: 208-364-3191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberM8489
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberM7975
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberM8195
License Number StateID
# 4
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberM7481
License Number StateID

VIII. Authorized Official

Name: KIRSTEN GRUNZKE
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 208-364-3000