Healthcare Provider Details

I. General information

NPI: 1992759930
Provider Name (Legal Business Name): IDAHO SURGICENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 01/31/2022
Certification Date: 01/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1157 CALL PLACE
POCATELLO ID
83201
US

IV. Provider business mailing address

PO BOX 2067
POCATELLO ID
83206-2067
US

V. Phone/Fax

Practice location:
  • Phone: 208-238-6337
  • Fax: 208-776-5510
Mailing address:
  • Phone: 208-238-6337
  • Fax: 208-776-5510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberP166
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberP92
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberP153
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. SEAN BARNARD
Title or Position: ADMINISTRATOR
Credential:
Phone: 208-852-6242