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Organization
IDAHO FALLS SURCIGAL CENTER
Active
Organization
IDAHO FALLS SURCIGAL CENTER
Active
Other names
Idaho Falls Surgical Center ASC
Organization subpart
No
Provider details
NPI number
Authorized official
MARK L PETERSEN MD (PRESIDENT)
(208) 529-1945
Entity
Organization
Contact information
Practice address
1945 E 17TH ST, IDAHO FALLS, ID 83404-6429
(208) 529-1945
(208) 529-1961
Mailing address
PO BOX 52180, IDAHO FALLS, ID 83405-2180
(208) 523-4906
(208) 523-2025
Taxonomy
Speciality
Code
Description
License number
State
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
13-C0001000
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
002512900
—
ID
01
—
490000095
RAILROAD MEDICARE
—
Enumeration date
11/08/2006
Last updated
06/09/2008
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