Provider Demographics
NPI:1124185053
Name:TWIN FALLS IMAGING & DIAGNOSTIC CENTER LLC
Entity Type:Organization
Organization Name:TWIN FALLS IMAGING & DIAGNOSTIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:L
Authorized Official - Last Name:SURBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-732-1205
Mailing Address - Street 1:562 SHOUP AVE W
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5029
Mailing Address - Country:US
Mailing Address - Phone:208-732-1205
Mailing Address - Fax:208-736-2413
Practice Address - Street 1:562 SHOUP AVE W
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5029
Practice Address - Country:US
Practice Address - Phone:208-732-1205
Practice Address - Fax:208-736-2413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1790379Medicare PIN