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General NPI Number Information
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NPI Number | 1184899973
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Entity Type | Organization
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Legal Business Name | IDAHO CLEFT AND CRANIOFACIAL PEDIATRIC PLASTIC SURGERY, P.A.
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Dates
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Enumeration Date | 04/23/2008
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Last Update Date | 05/08/2023
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Provider Practice Location Address
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Address Line | 100 E IDAHO STREET, SUITE 303
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City | BOISE
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State | ID
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Zip | 83712-6269
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Country | US
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Telephone | 208-433-1736
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Fax | 208-433-1738
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Provider Business Mailing Address
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Address Line | 100 E IDAHO STREET, SUITE 303
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City | BOISE
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State | ID
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Zip | 83712-6269
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Country | US
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Telephone | 208-433-1736
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Fax | 208-433-1738
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Authorized Official
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Title or Position | PRESIDENT
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Name | RUSSELL H GRIFFITHS
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Credential | MD
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Telephone | 208-433-1736
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number | M7454
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License Number State | ID
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