Provider Demographics
NPI:1235327446
Name:MACIESKI CRNA PC
Entity Type:Organization
Organization Name:MACIESKI CRNA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:C
Authorized Official - Last Name:MACIESKI
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:208-523-5172
Mailing Address - Street 1:PO BOX 3530
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-3530
Mailing Address - Country:US
Mailing Address - Phone:208-523-4906
Mailing Address - Fax:208-523-2025
Practice Address - Street 1:2325 CORONADO ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7407
Practice Address - Country:US
Practice Address - Phone:208-557-2700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-12
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty