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General NPI Number Information
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NPI Number | 1053481218
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Entity Type | Organization
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Legal Business Name | IDAHO FALLS SURCIGAL CENTER
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Dates
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Enumeration Date | 11/08/2006
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Last Update Date | 06/09/2008
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Provider Practice Location Address
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Address Line | 1945 E 17TH ST
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City | IDAHO FALLS
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State | ID
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Zip | 83404-6429
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Country | US
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Telephone | 208-529-1945
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Fax | 208-529-1961
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Provider Business Mailing Address
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Address Line | PO BOX 52180
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City | IDAHO FALLS
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State | ID
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Zip | 83405-2180
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Country | US
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Telephone | 208-523-4906
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Fax | 208-523-2025
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Authorized Official
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Title or Position | PRESIDENT
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Name | MARK L PETERSEN
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Credential | MD
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Telephone | 208-529-1945
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 13-C0001000
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License Number State | ID
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