Provider Demographics
NPI:1114938909
Name:BOISE MINOR EMERGENCY CENTER PA
Entity Type:Organization
Organization Name:BOISE MINOR EMERGENCY CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:CANOVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-378-0400
Mailing Address - Street 1:2993 N COLE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5977
Mailing Address - Country:US
Mailing Address - Phone:208-378-0400
Mailing Address - Fax:208-378-7529
Practice Address - Street 1:2993 N COLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5977
Practice Address - Country:US
Practice Address - Phone:208-378-0400
Practice Address - Fax:208-378-7529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1372012Medicare ID - Type UnspecifiedMEDICARE #