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General NPI Number Information
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NPI Number | 1316186927
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Entity Type | Organization
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Legal Business Name | NORTH IDAHO PLASTIC AND RECONSTRUCTIVE SURGERY INC.
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Dates
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Enumeration Date | 02/05/2009
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Last Update Date | 02/05/2009
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Provider Practice Location Address
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Address Line | 750 N SYRINGA ST STE 204
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City | POST FALLS
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State | ID
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Zip | 83854-5275
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Country | US
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Telephone | 208-777-7830
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Fax | 208-777-7850
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Provider Business Mailing Address
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Address Line | 750 N SYRINGA ST STE 204
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City | POST FALLS
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State | ID
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Zip | 83854-5275
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Country | US
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Telephone | 208-777-7830
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Fax | 208-777-7850
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. FREDERICK M OWSLEY
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Credential | M.D.
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Telephone | 208-777-7830
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | M-6071
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License Number State | ID
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