NPIMap

Organization Active NPI

Idaho Skin Surgery Center, PC

  • Dermatology Physician
  • Boise, ID
National Provider Identifier
1295908127
Registry record updated Dec 12, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
License
M-10116 Issued in ID
Legal business name
IDAHO SKIN SURGERY CENTER, PC
Practice address
1906 S Vista Ave
Boise, ID 83705-3453
Phone
(208) 433-1114
Fax
(208) 433-1115
NPI assigned
Apr 11, 2008
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 12, 2014

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

Authorized official

Name
Jared Scott, MDNPI 1992808893
Title
President
Phone
(208) 433-1114

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 3

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207N00000X M-10116 ID Primary
MOHS-Micrographic Surgery PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207ND0101X M-10116 ID
Procedural Dermatology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207NS0135X M-10116 ID

Addresses

Primary practice location

1906 S Vista Ave
Boise, ID 83705-3453

Mailing address

1906 S Vista Ave
Boise, ID 83705-3453
Phone (208) 433-1114

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20080815000236 ID Part B Supplier - Clinic/Group Practice 9537234299 Receives reassigned benefits from 5 practitioners
Practice locations: Boise, ID

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
13D1084633Idaho Skin Surgery Center1906 S Vista Ave, Boise, ID 83705ComplianceJun 1, 2027

National Provider Directory

National Provider Directory

Locations

1906 S Vista Ave
Ste A
Boise, ID 83705
Phone (208) 433-1114

Ownership & related parties

Subparts reporting this organization as parent 1

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1207872000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1418342400000",
    "number": "1295908127",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1906 S VISTA AVE",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837053453",
            "telephone_number": "208-433-1114",
            "fax_number": "208-433-1115"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1906 S VISTA AVE",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837053453",
            "telephone_number": "208-433-1114",
            "fax_number": "208-433-1115"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IDAHO SKIN SURGERY CENTER, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-04-11",
        "last_updated": "2014-12-12",
        "status": "A",
        "authorized_official_last_name": "SCOTT",
        "authorized_official_first_name": "JARED",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "208-433-1114",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dermatology",
            "state": "ID",
            "license": "M-10116",
            "primary": true
        },
        {
            "code": "207ND0101X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dermatology, MOHS-Micrographic Surgery",
            "state": "ID",
            "license": "M-10116",
            "primary": false
        },
        {
            "code": "207NS0135X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dermatology, Procedural Dermatology",
            "state": "ID",
            "license": "M-10116",
            "primary": false
        }
    ],
    "identifiers": [],
    "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 Dec 12, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.