Provider Demographics
NPI:1144413154
Name:EAST IDAHO ORTHOPAEDICS, PLLC
Entity Type:Organization
Organization Name:EAST IDAHO ORTHOPAEDICS, PLLC
Other - Org Name:LILJENQUIST & REDD ORTHOPEDIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:R
Authorized Official - Last Name:LILJENQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-522-3355
Mailing Address - Street 1:2210 CORONADO ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7430
Mailing Address - Country:US
Mailing Address - Phone:208-522-3355
Mailing Address - Fax:208-522-6019
Practice Address - Street 1:2210 CORONADO ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7430
Practice Address - Country:US
Practice Address - Phone:208-522-3355
Practice Address - Fax:208-522-6019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-10197207X00000X
IDM9781207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807709400Medicaid
4195631Medicare PIN
IDI63346Medicare UPIN