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General NPI Number Information
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NPI Number | 1760581409
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Entity Type | Organization
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Legal Business Name | BOISE SHOULDER CLINIC, PA
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Dates
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Enumeration Date | 09/21/2006
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Last Update Date | 02/13/2012
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Provider Practice Location Address
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Address Line | 3381 W BAVARIA STREET
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City | EAGLE
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State | ID
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Zip | 83616-5341
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Country | US
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Telephone | 208-639-4800
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Fax | 208-639-4801
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Provider Business Mailing Address
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Address Line | 3381 W BAVARIA STREET
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City | EAGLE
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State | ID
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Zip | 83616-5341
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Country | US
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Telephone | 208-639-4800
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Fax | 208-639-4801
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Authorized Official
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Title or Position | OWNER
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Name | DR. CARL SCOTT HUMPHREY
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Credential | MD
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Telephone | 208-639-4800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | M9563
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License Number State | ID
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