Organization
BOISE SURGICAL GROUP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KIRSTEN GRUNZKE (PRACTICE ADMINISTRATOR)
(208) 364-3000
Entity
Organization
Contact information
Practice address
3399 E. LOUISE DR., #400, MERIDIAN, ID 83642
(208) 364-3000
(208) 364-3191
Mailing address
3399 E. LOUISE DR., #400, MERIDIAN, ID 83642
(208) 364-3000
(208) 364-3191
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
M7481
ID
208600000X
Surgery Physician
M7975
ID
208600000X
Surgery Physician
M8195
ID
208600000X
Surgery Physician
M8489
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
002354900
—
ID
01
—
CI1633
RAILROAD MEDICARE
ID
Enumeration date
01/24/2007
Last updated
06/29/2010
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