Idaho Falls Surcigal Center

Primary specialty

Ambulatory Surgical Clinic/CenterTaxonomy code 261QA1903X

License

13-C0001000 Issued in ID

Legal business name

IDAHO FALLS SURCIGAL CENTER

Practice address

1945 E 17TH St
Idaho Falls, ID 83404-6429

Phone

(208) 529-1945

Fax

(208) 529-1961

NPI assigned

Nov 8, 2006

Last updated

Jun 9, 2008By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mark L Petersen, MD

Title

President

Phone

(208) 529-1945

Specialties & licenses 1

Addresses

Other identifiers 2

Other names 1

• Idaho Falls Surgical Center ASC Other name

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1162944000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1212969600000",
    "number": "1053481218",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 52180",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834052180",
            "telephone_number": "208-523-4906",
            "fax_number": "208-523-2025"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1945 E 17TH ST",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834046429",
            "telephone_number": "208-529-1945",
            "fax_number": "208-529-1961"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IDAHO FALLS SURCIGAL CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-08",
        "last_updated": "2008-06-09",
        "status": "A",
        "authorized_official_last_name": "PETERSEN",
        "authorized_official_first_name": "MARK",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "208-529-1945",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QA1903X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ambulatory Surgical",
            "state": "ID",
            "license": "13-C0001000",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "002512900",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "490000095",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Idaho Falls Surgical Center ASC",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

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• Idaho Falls Recovery Center
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• Idaho Falls Surgical Center
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• Idaho Falls Surgical Specialists, PLLC
• Idaho Family Vision PLLC (Family Vision Associates)

• Ambulatory Surgical Clinic/Center in Idaho Falls, ID
• Providers in Idaho Falls, ID by specialty
• Ambulatory Surgical Clinic/Center in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 9, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.