Provider Demographics
NPI:1477798148
Name:IDAHO NEUROSURGICAL CENTER, PA
Entity Type:Organization
Organization Name:IDAHO NEUROSURGICAL CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:CACH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-542-1050
Mailing Address - Street 1:2375 E SUNNYSIDE RD
Mailing Address - Street 2:SUITE G
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8280
Mailing Address - Country:US
Mailing Address - Phone:208-542-1050
Mailing Address - Fax:
Practice Address - Street 1:2375 E SUNNYSIDE RD
Practice Address - Street 2:SUITE G
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8280
Practice Address - Country:US
Practice Address - Phone:208-542-1050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-10
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty