NPIMap

Organization Active NPI

Idaho Eyelid & Facial Plastic Surgery , PLLC

  • Ophthalmology Physician
  • Boise, ID
National Provider Identifier
1255401436
Registry record updated Apr 3, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Ophthalmology PhysicianTaxonomy code 207W00000X
Legal business name
IDAHO EYELID & FACIAL PLASTIC SURGERY , PLLC
Practice address
111 W Main St Ste 200
Boise, ID 83702-7308
Phone
(208) 344-3220
Fax
(208) 344-0461
NPI assigned
Nov 8, 2006
Last updated
Apr 3, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 3, 2020

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

Authorized official

Name
Dr. Mark J Boerner, M.D.NPI 1003819459
Title
Owner
Phone
(208) 344-3220

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Optometrist 152W00000X NU
Ophthalmology Physician 207W00000X NU Primary

Addresses

Primary practice location

111 W Main St Ste 200
Boise, ID 83702-7308

Mailing address

111 W Main St Ste 200
Boise, ID 83702-7308
Phone (208) 344-3220

Other identifiers 4

IdentifierTypeStateIssuer
000010027884OtherIDREGENCE BLUE SHIELD
8F488OtherIDBLUE CROSS OF IDAHO
CJ6700OtherIDMEDICARE RR
806295400MedicaidID

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050405000613 ID Part B Supplier - Clinic/Group Practice 3375457906 Receives reassigned benefits from 3 practitioners
Practice locations: Boise, ID; Meridian, ID

National Provider Directory

National Provider Directory

Locations

111 W Main St
Boise, ID 83702
Phone (208) 342-7400

3090 E Gentry Way
Meridian, ID 83642
Phone (208) 288-1600

Practitioners & affiliated clinicians

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1162944000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1585872000000",
    "number": "1255401436",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "111 W MAIN ST STE 200",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837027308",
            "telephone_number": "208-344-3220",
            "fax_number": "208-344-0461"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "111 W MAIN ST STE 200",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837027308",
            "telephone_number": "208-344-3220",
            "fax_number": "208-344-0461"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IDAHO EYELID & FACIAL PLASTIC SURGERY , PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-08",
        "last_updated": "2020-04-03",
        "certification_date": "2020-04-03",
        "status": "A",
        "authorized_official_last_name": "BOERNER",
        "authorized_official_first_name": "MARK",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "208-344-3220",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207W00000X",
            "taxonomy_group": "",
            "desc": "Ophthalmology",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "REGENCE BLUE SHIELD",
            "identifier": "000010027884",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS OF IDAHO",
            "identifier": "8F488",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE RR",
            "identifier": "CJ6700",
            "state": "ID"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "806295400",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Boise, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 3, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.