Provider Demographics
NPI:1083998827
Name:BOISE SPINE SURGERY P.A.
Entity Type:Organization
Organization Name:BOISE SPINE SURGERY P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:M
Authorized Official - Last Name:VERSKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-378-7700
Mailing Address - Street 1:8756 W. EMERALD STREET
Mailing Address - Street 2:SUITE 176
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-4834
Mailing Address - Country:US
Mailing Address - Phone:208-378-7700
Mailing Address - Fax:208-378-7701
Practice Address - Street 1:8756 W. EMERALD STREET
Practice Address - Street 2:SUITE 176
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4834
Practice Address - Country:US
Practice Address - Phone:208-378-7700
Practice Address - Fax:208-378-7701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-28
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-6736207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID2754500Medicaid
ID2754500Medicaid