Organization
IDAHO EYELID & FACIAL PLASTIC SURGERY , PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MARK J BOERNER M.D. (OWNER)
(208) 344-3220
Entity
Organization
Contact information
Practice address
111 W MAIN ST STE 200, BOISE, ID 83702-7308
(208) 344-3220
(208) 344-0461
Mailing address
111 W MAIN ST STE 200, BOISE, ID 83702-7308
(208) 344-3220
(208) 344-0461
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
—
—
207W00000X
Ophthalmology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010027884
REGENCE BLUE SHIELD
ID
05
—
806295400
—
ID
01
—
8F488
BLUE CROSS OF IDAHO
ID
01
—
CJ6700
MEDICARE RR
ID
Enumeration date
11/08/2006
Last updated
04/03/2020
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