Healthcare Provider Details

I. General information

NPI: 1437237989
Provider Name (Legal Business Name): MADISON GENERAL SURGERY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

393 E 2ND N
REXBURG ID
83440-1605
US

IV. Provider business mailing address

PO BOX 310
REXBURG ID
83440-0310
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-9086
  • Fax: 208-356-3111
Mailing address:
  • Phone: 208-356-9086
  • Fax: 208-356-3111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number40
License Number StateID

VIII. Authorized Official

Name: CALVIN W CAREY
Title or Position: CFO
Credential:
Phone: 208-356-3691