Organization
AMBULATORY SURGERY CENTER OF BURLEY, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JOSEPH R. PETERSEN M.D. (CEO)
(208) 677-8888
Entity
Organization
Contact information
Practice address
1344 HILAND AVE, SUITE E, BURLEY, ID 83318-1564
(208) 677-8888
(208) 678-5833
Mailing address
1344 HILAND AVE, SUITE E, BURLEY, ID 83318-1564
(208) 677-8888
(208) 675-5833
Taxonomy
Speciality
Code
Description
License number
State
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
—
—
367500000X
Certified Registered Nurse Anesthetist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
03822
BLUE CROSS
ID
01
—
24973 000010005417
BLUE SHIELD
ID
05
—
805534000
—
ID
Enumeration date
08/02/2005
Last updated
08/17/2017
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