Provider Demographics
NPI:1114923471
Name:SURGICARE CENTER OF IDAHO, LLC
Entity Type:Organization
Organization Name:SURGICARE CENTER OF IDAHO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PENNOW
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:208-336-8700
Mailing Address - Street 1:360 E MALLARD DR
Mailing Address - Street 2:STE 125
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-6644
Mailing Address - Country:US
Mailing Address - Phone:208-336-8700
Mailing Address - Fax:208-426-0902
Practice Address - Street 1:360 E MALLARD DR
Practice Address - Street 2:STE 125
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3941
Practice Address - Country:US
Practice Address - Phone:208-336-8700
Practice Address - Fax:208-426-0902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID273390Medicaid
ID490004468Medicare PIN
ID273390Medicaid