Healthcare Provider Details

I. General information

NPI: 1255520037
Provider Name (Legal Business Name): IDAHO PAIN CENTER AND ANESTHESIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 07/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

286 N GATEWAY DR
PROVIDENCE UT
84332-9733
US

IV. Provider business mailing address

286 N GATEWAY DR STE 201
PROVIDENCE UT
84332-5602
US

V. Phone/Fax

Practice location:
  • Phone: 435-755-9184
  • Fax: 435-755-9148
Mailing address:
  • Phone: 435-755-9174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number329116-1204
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number329116-1204
License Number StateUT

VIII. Authorized Official

Name: SHANNA BEDELL
Title or Position: ACCOUNTS MANAGER
Credential:
Phone: 435-755-0964