Healthcare Provider Details

I. General information

NPI: 1699508929
Provider Name (Legal Business Name): CRESWELL FOOT & ANKLE SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2024
Last Update Date: 08/22/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

858 COMMERCE DR. SUITE 101
SMELTERVILLE ID
83868
US

IV. Provider business mailing address

PO BOX 483
SMELTERVILLE ID
83868-0483
US

V. Phone/Fax

Practice location:
  • Phone: 208-784-8777
  • Fax: 208-784-3533
Mailing address:
  • Phone: 801-550-4051
  • Fax: 208-784-8777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: JIMMY PRICE
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 832-277-6870