MEDICARE: IDAHOSURGEONS NET PC

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
1	2086S0127X	Trauma Surgery Physician	G151173	CA

General Provider Information

NPI Number	:	1295237022
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDAHOSURGEONS NET PC

Provider Business Mailing Address
First Line	:	7910 FROST ST STE 250
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-2752
Country	:	US
Telephone Number	:	858-565-0104
Fax Number	:	844-213-3678

Provider Business Practice Location Address
First Line	:	7910 FROST ST STE 250
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-2752
Country	:	US
Telephone Number	:	858-565-0104
Fax Number	:	844-213-3678

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JOHN C. MAYBERRY
Credential	:	MD
Telephone Number	:	858-565-0104

Provider Enumeration Date	:	03/07/2018
Last Update Date	:	03/22/2018

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