Organization
IDAHO ENDOSCOPY CENTER LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MARK A MALLORY M.D. (MANAGER/DOCTOR)
(208) 489-1900
Entity
Organization
Contact information
Practice address
6259 W EMERALD ST, BOISE, ID 83704-8731
(208) 489-1900
(208) 489-1929
Mailing address
6259 W EMERALD ST, BOISE, ID 83704-8731
(208) 489-1900
(208) 489-1929
Taxonomy
Speciality
Code
Description
License number
State
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1871902
MEDICARE PTAN
ID
Enumeration date
10/16/2009
Last updated
07/23/2020
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