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General NPI Number Information
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NPI Number | 1548433790
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Entity Type | Organization
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Legal Business Name | ADA PLASTIC AND RECONSTRUCTIVE SURGERY
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Dates
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Enumeration Date | 04/09/2008
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Last Update Date | 04/11/2008
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Provider Practice Location Address
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Address Line | 900 N LIBERTY ST SUITE 300
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City | BOISE
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State | ID
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Zip | 83704-8704
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Country | US
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Telephone | 208-367-6903
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Fax | 208-367-6904
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Provider Business Mailing Address
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Address Line | 900 N LIBERTY ST SUITE 300
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City | BOISE
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State | ID
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Zip | 83704-8704
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Country | US
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Telephone | 208-367-6903
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Fax | 208-367-6904
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Authorized Official
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Title or Position | OWNING PHYSICIAN
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Name | MR. THOMAS D MCKIM
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Credential | M.D.
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Telephone | 208-367-6901
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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 | M7009
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License Number State | ID
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