Provider Demographics
NPI:1285825075
Name:SUNNYSIDE SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:SUNNYSIDE SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:208-528-2858
Mailing Address - Street 1:3345 S HOLMES AVE STE B
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7981
Mailing Address - Country:US
Mailing Address - Phone:208-528-2858
Mailing Address - Fax:208-528-8022
Practice Address - Street 1:3345 S HOLMES AVE STE B
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7981
Practice Address - Country:US
Practice Address - Phone:208-528-2858
Practice Address - Fax:208-528-8022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP140-7261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID00010151664OtherBLUE SHIELD
ID04804OtherBLUE CROSS
ID1870633Medicare PIN
ID00010151664OtherBLUE SHIELD