Idaho Eye Center PA

Primary specialty

Ambulatory Surgical Clinic/CenterTaxonomy code 261QA1903X

Legal business name

IDAHO EYE CENTER PA

Practice address

2025 E 17TH St
Idaho Falls, ID 83404

Phone

(208) 524-2025

Fax

(208) 529-1924

NPI assigned

Nov 28, 2006

Organization subpart

Yes

Parent organization

IDAHO EYE CENTER PAAs reported in NPPES

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

Authorized official

Name

Dr. Bradley P Gardner, MDNPI 1255408217

Title

Senior Vice President

Phone

(208) 524-2025

Specialties & licenses 1

Addresses

Other identifiers 7

Other names 1

• Idaho Eye Surgicenter Other name

Medicare fee-for-service enrollment

Enrolled in ID4 enrollments

Enrollment records 4

Other NPIs with the same Medicare PAC ID 1

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

• Idaho Eye Center PA

  • Ophthalmology Physician
  • Idaho Falls, ID
  • NPI 1518021849

  1557358025

  Same PAC ID

Listed as

Idaho Eye Center RexburgCCN 13C0001066

Medicare certification status

ActiveFrom the Provider of Services file

Listed as

Idaho Eye Center PocatelloCCN 13C0001025

Medicare certification status

ActiveFrom the Provider of Services file

Listed as

Idaho Eye Center PACCN 13C0001004

Medicare certification status

ActiveFrom the Provider of Services file

Tax ID family

Idaho Eye Center PA2 organizations share this tax ID, including this one

Part of

Idaho Eye Center PA

Other organizations with this tax ID 1

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

• Idaho Eye Center PA

  • Ophthalmology Physician
  • Idaho Falls, ID
  • NPI 1518021849
  NPD tax ID

Locations

Practitioners 9

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

• Bradley P Gardner, MD

  • Ophthalmology Physician
  • Idaho Falls, ID
  • NPI 1255408217
  NPD Authorized official
• Richard Cannon, MD

  • Ophthalmology Physician
  • Idaho Falls, ID
  • NPI 1992842264
  NPD
• James R Davis, OD

  • Optometrist
  • Idaho Falls, ID
  • NPI 1326115395
  NPD
• Gregory Scott Emfield, D.O

  • Ophthalmology Physician
  • Pocatello, ID
  • NPI 1538594379
  NPD
• Spencer James Harris, MD

  • Cornea and External Diseases Specialist Physician
  • Idaho Falls, ID
  • NPI 1255892568
  NPD
• Eric K Romriell, DO

  • Ophthalmology Physician
  • Idaho Falls, ID
  • NPI 1922072586
  NPD
• Shane L Wynn, OD

  • Optometrist
  • Idaho Falls, ID
  • NPI 1427125491
  NPD
• Bradley Arvel Hansen, M.D.

  • Ophthalmology Physician
  • Boston, MA
  • NPI 1114284825
  NPD
• Kurt Perry Hepworth, O.D

  • Optometrist
  • South Jordan, UT
  • NPI 1457531428
  NPD

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

{
    "created_epoch": "1164672000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1218499200000",
    "number": "1629145685",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2025 E 17TH ST",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "83404",
            "telephone_number": "208-524-2025",
            "fax_number": "208-529-1924"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2025 E 17TH ST",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "83404",
            "telephone_number": "208-524-2025",
            "fax_number": "208-529-1924"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IDAHO EYE CENTER PA",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "IDAHO EYE CENTER PA",
        "enumeration_date": "2006-11-28",
        "last_updated": "2008-08-12",
        "status": "A",
        "authorized_official_last_name": "GARDNER",
        "authorized_official_first_name": "BRADLEY",
        "authorized_official_middle_name": "P",
        "authorized_official_title_or_position": "SENIOR VICE PRESIDENT",
        "authorized_official_telephone_number": "208-524-2025",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QA1903X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ambulatory Surgical",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "490000614",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "480000614",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS",
            "identifier": "00984",
            "state": "ID"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "002562201",
            "state": "ID"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "002565200",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "WYOMING MEDICAID",
            "identifier": "105947500",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS",
            "identifier": "5207",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Idaho Eye Surgicenter",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

• Idaho Dept of Health & Welfare Region 7 Amh PSR If
• Idaho Dept of Health & Welfare Region 7 CMH Clinic If
• Idaho Dept of Health & Welfare Region 7 CMH PSR If
• Idaho Direct Physical Therapy, PLLC
• Idaho Eye Center PA
• Idaho Eye Pros Idaho Falls LLC
• Idaho Falls Arthritis Clinic PC
• Idaho Falls ASC
• Idaho Falls Clinic, P.a.
• Idaho Falls Community Hospital LLC

• 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 Aug 12, 2008; 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.