# GREENWALD NEUROSURGICAL

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1124198403
- **Authorized official:** MS. JANEENE A DITMORE (OFFICE MANAGER)
- **Authorized official phone:** (208) 535-4800

## Contact information

- **Practice address:** 3155 CHANNING WAY, SUITE B, IDAHO FALLS, ID 83404-7546
- **Practice address phone:** (208) 535-4800
- **Practice address fax:** (208) 535-4807
- **Mailing address:** 3155 CHANNING WAY, SUITE B, IDAHO FALLS, ID 83404-7546
- **Mailing address phone:** (208) 535-4800
- **Mailing address fax:** (208) 535-4807

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 174400000X | Specialist | M-6947 | ID | Yes |

## Other

- **Enumeration date:** 11/08/2006
- **Last updated:** 07/13/2009

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 000010001551 | BLUE SHIELD | ID |
| 01 | — | 76836 | BLUE CROSS | ID |
| 01 | — | 8M987 | BLUE CROSS PRACTICE | ID |