NPIMap

Organization Active NPI

Idaho Physical Medicine and Rehabilitation PA

  • Ambulatory Surgical Clinic/Center
  • Meridian, ID
National Provider Identifier
1497949705
Registry record updated Jun 5, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Ambulatory Surgical Clinic/CenterTaxonomy code 261QA1903X
Legal business name
IDAHO PHYSICAL MEDICINE AND REHABILITATION PA
Practice address
3551 E Overland Road
Meridian, ID 83642
Phone
(208) 884-1333
NPI assigned
Aug 29, 2007
Last updated
Jun 5, 2014By the provider in NPPES
Organization subpart
Yes
Parent organization
IDAHO PHYSICIAL MEDICINE AND REHABILITATIONAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jun 5, 2014

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

Authorized official

Name
Kate A Shelton
Title
Administrator
Phone
(208) 287-6558

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Pain Medicine (Physical Medicine & Rehabilitation) PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 2081P2900X
Ambulatory Surgical Clinic/Center 261QA1903X ID Primary

Addresses

Primary practice location

3551 E Overland Road
Meridian, ID 83642

Mailing address

PO Box 1128
Boise, ID 83701-1128
Phone (208) 489-4016

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20071005000369 ID Part B Supplier - Ambulatory Surgical Center 3971579954 Practice locations: Meridian, ID

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1497949705. Details of each certification follow.

Ambulatory surgical center certification: CCN 13C0001064

Name & address match This certification has no NPI in the Medicare enrollment files. CMS publishes enrollment files for six facility types only, so it was connected to this NPI by matching the name and address CMS publishes for it.

Legal name
IDAHO PHYSICAL MEDICINE AND REHABILITATION
Certification status
Active
Provider type (POS)
Ambulatory surgical center
Participating since
Jan 30, 2008
Last certification
Jan 31, 2008
Ownership / control type
Proprietary
Facility address
3551 East Overland Road
Meridian, ID 83642

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
William R Prebola Jr MD2 organizations share this tax ID, including this one
Part of
William R Prebola Jr MD

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 16

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.

View all 16

NPI Registry JSON

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

{
    "created_epoch": "1188345600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1401926400000",
    "number": "1497949705",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1128",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837011128",
            "telephone_number": "208-489-4016",
            "fax_number": "208-489-4015"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3551 E OVERLAND ROAD",
            "city": "MERIDIAN",
            "state": "ID",
            "postal_code": "83642",
            "telephone_number": "208-884-1333"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IDAHO PHYSICAL MEDICINE AND REHABILITATION PA",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "IDAHO PHYSICIAL MEDICINE AND REHABILITATION",
        "enumeration_date": "2007-08-29",
        "last_updated": "2014-06-05",
        "status": "A",
        "authorized_official_last_name": "SHELTON",
        "authorized_official_first_name": "KATE",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "208-287-6558"
    },
    "taxonomies": [
        {
            "code": "2081P2900X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Physical Medicine & Rehabilitation, Pain Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QA1903X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ambulatory Surgical",
            "state": "ID",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Meridian, ID

Sources for this page

Verify at the official NPI Registry.