Healthcare Provider Details

I. General information

NPI: 1871016071
Provider Name (Legal Business Name): PORTNEUF ASC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2017
Last Update Date: 07/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 HOSPITAL WAY BLDG A
POCATELLO ID
83201-5091
US

IV. Provider business mailing address

1 BURTON HILLS BLVD STE 250
NASHVILLE TN
37215-6195
US

V. Phone/Fax

Practice location:
  • Phone: 208-232-6616
  • Fax: 208-232-6618
Mailing address:
  • Phone: 615-296-3000
  • Fax: 615-296-6227

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: STEPHEN C PETROVICH
Title or Position: EVP
Credential:
Phone: 615-296-3000