Organization
SURGICAL ASSOCIATES OF SOUTHERN ID
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. SCOTT SCHRADER PHYSICIAN ASSIATANT (PRESIDENT)
(208) 736-4568
Entity
Organization
Contact information
Practice address
650 ADDISON AVE W, TWIN FALLS, ID 83301-5444
(208) 737-2112
Mailing address
PO BOX 1657, TWIN FALLS, ID 83303-1657
(208) 734-3356
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
PA271
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010151672
BLUE SHIELD
ID
05
—
805592000
—
ID
01
—
PAWT9
BLUE CROSS
ID
Enumeration date
02/08/2007
Last updated
01/15/2010
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