=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821303298
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IDAHO FALLS SURGICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2010
-----------------------------------------------------
Last Update Date | 08/10/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1945 E 17TH ST
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83404-6429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-529-1945
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 52180
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83405-2180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-552-8764
-----------------------------------------------------
Fax | 208-523-2025
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRES
-----------------------------------------------------
Name | DR. MARK L PETERSEN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 208-529-1945
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------