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General NPI Number Information
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NPI Number | 1598817348
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Entity Type | Organization
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Legal Business Name | IDAHO SURGICAL PARTNERS, PC
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Dates
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Enumeration Date | 01/18/2007
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Last Update Date | 09/30/2024
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Provider Practice Location Address
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Address Line | 323 E RIVERSIDE DR STE 220
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City | EAGLE
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State | ID
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Zip | 83616-5246
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Country | US
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Telephone | 208-343-5600
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2045
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City | EAGLE
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State | ID
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Zip | 83616-9110
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Country | US
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Telephone | 208-343-5600
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Fax | 208-779-2889
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | AMI YANTIS
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Credential |
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Telephone | 208-649-8347
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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 | M6834
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License Number State | ID
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