Healthcare Provider Details

I. General information

NPI: 1851200034
Provider Name (Legal Business Name): BEAR RIVER FOOT AND ANKLE INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 E FAIRVIEW AVE
MERIDIAN ID
83642-1813
US

IV. Provider business mailing address

PO BOX 4184
BOISE ID
83711-4184
US

V. Phone/Fax

Practice location:
  • Phone: 208-617-3226
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: TYLER GLOSCHAT
Title or Position: OWNER
Credential: DPM
Phone: 208-617-3226