Organization
IDAHO EYE CENTER PA
Active
Parent organization
IDAHO EYE CENTER PA
Other names
Idaho Eye Surgicenter
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
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
002562201
—
ID
05
—
002565200
—
ID
01
—
00984
BLUE CROSS
ID
01
—
105947500
WYOMING MEDICAID
ID
01
—
480000614
RAILROAD MEDICARE
ID
01
—
490000614
RAILROAD MEDICARE
ID
01
—
5207
BLUE CROSS
ID
Enumeration date
11/28/2006
Last updated
08/12/2008
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