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Organization
REXBURG SURGERY CENTER LLC
Active
Organization
REXBURG SURGERY CENTER LLC
Active
Other names
North Fork Surgery Center
Organization subpart
No
Provider details
NPI number
Authorized official
DR. DWAYNE M HANSEN M.D. (BOARD CHAIRMAN)
(208) 359-2300
Entity
Organization
Contact information
Practice address
381 EAST 4TH NORTH, SUITE 200, REXBURG, ID 83440
(208) 359-2300
Mailing address
381 EAST 4TH NORTH, SUITE 200, REXBURG, ID 83440
(208) 359-2300
Taxonomy
Speciality
Code
Description
License number
State
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
—
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010158869
BLUE SHIELD PROVIDER NUMB
ID
01
—
04870
BLUE CROSS PROVIDER NUMBE
ID
05
—
80760000
—
ID
Enumeration date
06/17/2006
Last updated
08/22/2020
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