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General NPI Number Information
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NPI Number | 1477359909
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Entity Type | Organization
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Legal Business Name | GRANITE MOUNTAIN SURGERY PLLC
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Dates
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Enumeration Date | 02/24/2025
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Last Update Date | 02/24/2025
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Provider Practice Location Address
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Address Line | 8950 W EMERALD ST STE 195
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City | BOISE
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State | ID
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Zip | 83704-8296
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Country | US
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Telephone | 208-999-3034
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Fax |
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Provider Business Mailing Address
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Address Line | 8950 W EMERALD ST STE 195
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City | BOISE
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State | ID
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Zip | 83704-8296
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Country | US
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Telephone | 208-999-3034
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | AMBER L ELLIOTT
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Credential | MD
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Telephone | 208-412-4530
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number |
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License Number State |
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