Organization
SPINE INSTITUTE OF IDAHO P A
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. TYLER COOPER (OFFICE ASST ADMINISTRATOR)
(208) 855-2900
Entity
Organization
Contact information
Practice address
360 E MONTVUE DR, SUITE 100, MERIDIAN, ID 83642-6318
(208) 855-2900
(208) 898-9877
Mailing address
360 E MONTVUE DR, SUITE 100, MERIDIAN, ID 83642-6318
(208) 855-2900
(208) 898-9877
Taxonomy
Speciality
Code
Description
License number
State
207XS0117X
Orthopaedic Surgery of the Spine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
805983000
—
ID
Enumeration date
08/05/2006
Last updated
10/04/2016
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