Provider Demographics
NPI:1609839398
Name:SURGICAL GROUP, P.A.
Entity Type:Organization
Organization Name:SURGICAL GROUP, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:AGEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-459-0028
Mailing Address - Street 1:404 E ELM ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4846
Mailing Address - Country:US
Mailing Address - Phone:208-459-0028
Mailing Address - Fax:208-459-0380
Practice Address - Street 1:404 E ELM ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4846
Practice Address - Country:US
Practice Address - Phone:208-459-0028
Practice Address - Fax:208-459-0380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-11
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID87460OtherBLUE CROSS OF IDAHO
ID002483000Medicaid
ID002483000Medicaid