=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851200034
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEAR RIVER FOOT AND ANKLE INSTITUTE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2026
-----------------------------------------------------
Last Update Date | 09/03/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1130 E FAIRVIEW AVE
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-1813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-617-3226
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4184
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83711-4184
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TYLER GLOSCHAT
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 208-617-3226
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------