Organization
IDAHO EYE CENTER PA
Active
Parent organization
IDAHO EYE CENTER, PA
Organization subpart
Yes
Provider details
NPI number
Legal business name
IDAHO EYE CENTER, PA
Authorized official
DR. BRADLEY P GARDNER MD (SENIOR VICE PRESIDENT)
(208) 524-2025
Entity
Organization
Contact information
Practice address
2025 E 17TH ST, IDAHO FALLS, ID 83404
(208) 524-2025
(208) 529-1924
Mailing address
2025 E 17TH ST, IDAHO FALLS, ID 83404
(208) 524-2025
(208) 529-1924
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
84434
BLUE CROSS
ID
01
—
8C626
BLUE CROSS
ID
01
—
8E837
BLUE CROSS
ID
01
—
8F876
BLUE CROSS
ID
Enumeration date
12/21/2006
Last updated
08/20/2008
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