Organization
IDAHO FALLS SURGICAL CENTER
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARK L. PETERSEN MD (PRESIDENT)
(208) 529-1945
Entity
Organization
Contact information
Practice address
1945 E 17TH ST, IDAHO FALLS, ID 83404-6429
(208) 529-1945
Mailing address
PO BOX 52180, IDAHO FALLS, ID 83405-2180
(208) 529-1945
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
806687900
—
ID
01
—
DB0412
RAILROAD MEDICARE
—
Enumeration date
05/16/2008
Last updated
05/16/2008
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