Organization
GREENWALD NEUROSURGICAL PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. JANEENE ANNE DITMORE (OFFICE MANAGER)
(208) 535-4800
Entity
Organization
Contact information
Practice address
3155 CHANNING WAY, SUITE B, IDAHO FALLS, ID 83404-7561
(208) 535-4800
(208) 535-4807
Mailing address
3155 CHANNING WAY, SUITE B, IDAHO FALLS, ID 83404-7561
(208) 535-4800
(208) 535-4807
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010001551
BLUE SHIELD
ID
01
—
76836
BLUE CROSS
ID
01
—
8M987
BLUE CROSS PRACTICE
ID
Enumeration date
12/08/2006
Last updated
06/25/2009
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