Provider Demographics
NPI:1114013869
Name:ROCKY MOUNTAIN SURGERY CENTER
Entity Type:Organization
Organization Name:ROCKY MOUNTAIN SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:STOCKER
Authorized Official - Suffix:
Authorized Official - Credentials:CPC-H
Authorized Official - Phone:208-234-7800
Mailing Address - Street 1:333 N 18TH AVE STE C
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3358
Mailing Address - Country:US
Mailing Address - Phone:208-234-7800
Mailing Address - Fax:208-234-9515
Practice Address - Street 1:333 N 18TH AVE STE C
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3358
Practice Address - Country:US
Practice Address - Phone:208-234-7800
Practice Address - Fax:208-234-9515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1870228Medicare ID - Type UnspecifiedAMBULATORY SURGERY CENTER