Healthcare Provider Details

I. General information

NPI: 1144267022
Provider Name (Legal Business Name): BLUE LAKES GASTROENTEROLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 03/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 POLE LINE RD W SUITE 203
TWIN FALLS ID
83301-5814
US

IV. Provider business mailing address

775 POLE LINE RD W SUITE 203
TWIN FALLS ID
83301-5814
US

V. Phone/Fax

Practice location:
  • Phone: 208-814-8300
  • Fax: 208-733-8970
Mailing address:
  • Phone: 208-814-8300
  • Fax: 208-733-8970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberM6665
License Number StateID

VIII. Authorized Official

Name: ROBERT WARD
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 208-814-8300