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NPI Code Detail

MEDICARE: BOISE ENDOSCOPY CENTER, LLC

MEDICARE: BOISE ENDOSCOPY CENTER, LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QA1903XAmbulatory Surgical Clinic/Center1870273ID

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1000010005291OTHERIDBLUE SHIELD OF IDAHO
204580OTHERIDBLUE CROSS OF IDAHO
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1114912102
Entity Type Code : Organization
Provider Name (Legal Business Name) : BOISE ENDOSCOPY CENTER, LLC
Provider Business Mailing Address
First Line : 425 W BANNOCK ST
Second Line :
City : BOISE
State : ID
Zip : 83702-6035
Country : US
Telephone Number : 208-342-7169
Fax Number : 208-368-0863
Provider Business Practice Location Address
First Line : 425 W BANNOCK ST
Second Line :
City : BOISE
State : ID
Zip : 83702-6035
Country : US
Telephone Number : 208-342-7169
Fax Number : 208-368-0863
Authorized Official
Title or Position : CREDENTIALING MANAGER
Name : REBECCA PAHSSEN
Credential :
Telephone Number : 208-489-1431
Provider Enumeration Date : 09/15/2005
Last Update Date : 12/08/2022

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Directions to “BOISE ENDOSCOPY CENTER, LLC ” Practice Location

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