# MOUNTAIN STATES CARDIOVASCULAR AND

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Mountain States Cardiovascular and Thoracic Surgery, PLLC
- **Organization subpart:** No

## Provider details

- **NPI number:** 1306862503
- **Authorized official:** LISA A ALCOX (OFFICE MANAGER)
- **Authorized official phone:** (208) 524-4660

## Contact information

- **Practice address:** 2225 TETON PLZ STE B, IDAHO FALLS, ID 83404-6494
- **Practice address phone:** (208) 524-4660
- **Mailing address:** 2225 TETON PLZ STE B, IDAHO FALLS, ID 83404-6494
- **Mailing address phone:** (208) 524-4660
- **Mailing address fax:** (208) 524-4617

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 174400000X | Specialist | M-6479 M-7194 | ID | Yes |

## Other

- **Enumeration date:** 07/14/2006
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 29390 | BLUE SHIELD GROUP \# | ID |
| 01 | — | 8A943 | BLUE CROSS GROUP \# | ID |