Provider Demographics
NPI:1295189918
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:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALEXIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:BERGESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-932-4133
Mailing Address - Street 1:3405 MERLIN DR
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 1:3405 MERLIN DR
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:2016-04-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-9781207X00000X, 207XX0005X
IDM-10197207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty