Healthcare Provider Details

I. General information

NPI: 1033127659
Provider Name (Legal Business Name): SURGICAL BARIATRICS NORTHWEST, INC. P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 07/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 N SYRINGA ST SUITE 205
POST FALLS ID
83854-5275
US

IV. Provider business mailing address

750 N SYRINGA ST SUITE 205
POST FALLS ID
83854-5275
US

V. Phone/Fax

Practice location:
  • Phone: 208-262-0945
  • Fax: 208-415-0150
Mailing address:
  • Phone: 208-262-0945
  • Fax: 208-415-0150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN L. PENNINGS
Title or Position: PRESIDENT
Credential: MD
Phone: 208-262-0945