Organization
MOUNTAIN STATES CARDIOVASCULAR AND
Active
Other names
Mountain States Cardiovascular and Thoracic Surgery, PLLC
Organization subpart
No
Provider details
NPI number
Authorized official
LISA A ALCOX (OFFICE MANAGER)
(208) 524-4660
Entity
Organization
Contact information
Practice address
2225 TETON PLZ STE B, IDAHO FALLS, ID 83404-6494
(208) 524-4660
Mailing address
2225 TETON PLZ STE B, IDAHO FALLS, ID 83404-6494
(208) 524-4660
(208) 524-4617
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
M-6479 M-7194
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
29390
BLUE SHIELD GROUP #
ID
01
—
8A943
BLUE CROSS GROUP #
ID
Enumeration date
07/14/2006
Last updated
08/22/2020
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