Healthcare Provider Details

I. General information

NPI: 1013482207
Provider Name (Legal Business Name): GRIFFIN ANESTHESIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2018
Last Update Date: 10/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1157 CALL PL
POCATELLO ID
83201-4008
US

IV. Provider business mailing address

PO BOX 3503
IDAHO FALLS ID
83403-3503
US

V. Phone/Fax

Practice location:
  • Phone: 208-238-6337
  • Fax:
Mailing address:
  • Phone: 208-525-2090
  • Fax: 208-523-8978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: GARY GRIFFIN
Title or Position: OWNER
Credential: CRNA
Phone: 208-251-9958