MEDICARE: IDAHO SURGERY 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
1	261QA1903X	Ambulatory Surgical Clinic/Center		ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386614519
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDAHO SURGERY CENTER, LLC

Provider Business Mailing Address
First Line	:	3115 MEDICAL DRIVE
Second Line	:
City	:	CALDWELL
State	:	ID
Zip	:	83605-6972
Country	:	US
Telephone Number	:	208-453-8668
Fax Number	:	208-453-8448

Provider Business Practice Location Address
First Line	:	3115 MEDICAL DRIVE
Second Line	:
City	:	CALDWELL
State	:	ID
Zip	:	83605-6972
Country	:	US
Telephone Number	:	208-453-8668
Fax Number	:	208-453-8448

Authorized Official
Title or Position	:	BUSINESS OFFICE MANAGER
Name	:	KATHY HOGUE
Credential	:
Telephone Number	:	208-453-8668

Provider Enumeration Date	:	01/23/2006
Last Update Date	:	08/31/2011

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