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Organization
AMBULATORY SURGERY CENTER OF BURLEY, LLC
Active
Organization
AMBULATORY SURGERY CENTER OF BURLEY, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JOSEPH R. PETERSEN M.D. (CEO)
(208) 677-8888
Entity
Organization
Contact information
Practice address
1344 HILAND AVE, SUITE E, BURLEY, ID 83318-1564
(208) 677-8888
(208) 678-5833
Mailing address
1344 HILAND AVE, SUITE E, BURLEY, ID 83318-1564
(208) 677-8888
(208) 675-5833
Taxonomy
Speciality
Code
Description
License number
State
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
—
—
367500000X
Certified Registered Nurse Anesthetist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
03822
BLUE CROSS
ID
01
—
24973 000010005417
BLUE SHIELD
ID
05
—
805534000
—
ID
Enumeration date
08/02/2005
Last updated
08/17/2017
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