Provider Demographics
NPI:1124198403
Name:GREENWALD NEUROSURGICAL
Entity Type:Organization
Organization Name:GREENWALD NEUROSURGICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JANEENE
Authorized Official - Middle Name:A
Authorized Official - Last Name:DITMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-535-4800
Mailing Address - Street 1:3155 CHANNING WAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7546
Mailing Address - Country:US
Mailing Address - Phone:208-535-4800
Mailing Address - Fax:208-535-4807
Practice Address - Street 1:3155 CHANNING WAY
Practice Address - Street 2:SUITE B
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7546
Practice Address - Country:US
Practice Address - Phone:208-535-4800
Practice Address - Fax:208-535-4807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-6947174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID76836OtherBLUE CROSS
ID8M987OtherBLUE CROSS PRACTICE
ID000010001551OtherBLUE SHIELD
IDG20851Medicare UPIN
ID000010001551OtherBLUE SHIELD