Provider Demographics
NPI:1114912102
Name:BOISE ENDOSCOPY CENTER, LLC
Entity Type:Organization
Organization Name:BOISE ENDOSCOPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:PAHSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-489-1431
Mailing Address - Street 1:425 W BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6035
Mailing Address - Country:US
Mailing Address - Phone:208-342-7169
Mailing Address - Fax:208-368-0863
Practice Address - Street 1:425 W BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6035
Practice Address - Country:US
Practice Address - Phone:208-342-7169
Practice Address - Fax:208-368-0863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-15
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1870273261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010005291OtherBLUE SHIELD OF IDAHO
ID04580OtherBLUE CROSS OF IDAHO
ID805944300Medicaid
ID805944300Medicaid