NPIMap

Organization Active NPI

Ambulatory Surgery Center of Burley, LLC

  • Ambulatory Surgical Clinic/Center
  • Burley, ID
National Provider Identifier
1992706840
Registry record updated Aug 17, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Ambulatory Surgical Clinic/CenterTaxonomy code 261QA1903X
Legal business name
AMBULATORY SURGERY CENTER OF BURLEY, LLC
Practice address
1344 Hiland Ave
Suite E
Burley, ID 83318-1564
Phone
(208) 677-8888
Fax
(208) 678-5833
NPI assigned
Aug 2, 2005
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 17, 2017

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

Authorized official

Name
Dr. Joseph R. Petersen, M.D.NPI 1225105604
Title
Ceo
Phone
(208) 677-8888

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
Ambulatory Surgical Clinic/Center 261QA1903X Primary
Certified Registered Nurse AnesthetistGroup: 193200000X MULTI-SPECIALTY GROUP 367500000X

Addresses

Primary practice location

1344 Hiland Ave
Suite E
Burley, ID 83318-1564

Mailing address

1344 Hiland Ave
Suite E
Burley, ID 83318-1564
Phone (208) 677-8888

Other identifiers 3

IdentifierTypeStateIssuer
805534000MedicaidID
24973 000010005417OtherIDBLUE SHIELD
03822OtherIDBLUE CROSS

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20091204000125 ID Part B Supplier - Ambulatory Surgical Center 7517006596 Receives reassigned benefits from 12 practitioners
Practice locations: Burley, ID

Care Compare: Ambulatory surgical center

Medicare Care Compare
Listed as
Ambulatory Surgery Center of Burley LLCCCN 13C0001028
Medicare certification status
ActiveFrom the Provider of Services file

National Provider Directory

National Provider Directory
Tax ID family
Ambulatory Surgery Cent2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

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

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

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 13

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

View all 13

NPI Registry JSON

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

{
    "created_epoch": "1122940800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1502928000000",
    "number": "1992706840",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1344 HILAND AVE",
            "address_2": "SUITE E",
            "city": "BURLEY",
            "state": "ID",
            "postal_code": "833181564",
            "telephone_number": "208-677-8888",
            "fax_number": "208-675-5833"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1344 HILAND AVE",
            "address_2": "SUITE E",
            "city": "BURLEY",
            "state": "ID",
            "postal_code": "833181564",
            "telephone_number": "208-677-8888",
            "fax_number": "208-678-5833"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "AMBULATORY SURGERY CENTER OF BURLEY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-08-02",
        "last_updated": "2017-08-17",
        "status": "A",
        "authorized_official_last_name": "PETERSEN",
        "authorized_official_first_name": "JOSEPH",
        "authorized_official_middle_name": "R.",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "208-677-8888",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "261QA1903X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ambulatory Surgical",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "367500000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Anesthetist, Certified Registered",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "805534000",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE SHIELD",
            "identifier": "24973 000010005417",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS",
            "identifier": "03822",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Burley, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 17, 2017; 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.