Healthcare Provider Details

I. General information

NPI: 1609825298
Provider Name (Legal Business Name): SURGERY CENTER OF IDAHO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 02/22/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2855 E MAGIC VIEW DR
MERIDIAN ID
83642-6245
US

IV. Provider business mailing address

2855 E MAGIC VIEW DR
MERIDIAN ID
83642-6245
US

V. Phone/Fax

Practice location:
  • Phone: 208-639-4900
  • Fax: 208-639-4919
Mailing address:
  • Phone: 208-639-4900
  • Fax: 208-639-4919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TODD MICHAEL WALDMANN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 208-639-4900