Provider Demographics
NPI:1477195931
Name:JARRELL PLASTIC SURGERY
Entity Type:Organization
Organization Name:JARRELL PLASTIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:JARRELL
Authorized Official - Suffix:IV
Authorized Official - Credentials:MD
Authorized Official - Phone:208-810-2245
Mailing Address - Street 1:PO BOX 4885
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83711-4885
Mailing Address - Country:US
Mailing Address - Phone:208-810-2245
Mailing Address - Fax:208-947-3465
Practice Address - Street 1:3090 E GENTRY WAY STE 210
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-3550
Practice Address - Country:US
Practice Address - Phone:208-810-2245
Practice Address - Fax:208-947-3465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-16
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty