Provider Demographics
NPI:1629043252
Name:PARK CENTER FOOT AND ANKLE
Entity Type:Organization
Organization Name:PARK CENTER FOOT AND ANKLE
Other - Org Name:PARK CENTER FOOT & ANKLE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:ALYSSA
Authorized Official - Middle Name:
Authorized Official - Last Name:BARBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-387-0900
Mailing Address - Street 1:671 E. RIVERPARK LANE
Mailing Address - Street 2:STE 110
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706
Mailing Address - Country:US
Mailing Address - Phone:208-387-0900
Mailing Address - Fax:208-345-5883
Practice Address - Street 1:671 E. RIVERPARK LANE
Practice Address - Street 2:STE 110
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-387-0900
Practice Address - Fax:208-345-5883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-17
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP142213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002725800Medicaid
IDP1423OtherBLUE CROSS OF ID
ID000010015660OtherREGENCE BS OF ID
DA8994OtherRAILROAD MEDICARE
U43496Medicare UPIN
ID000010015660OtherREGENCE BS OF ID
ID002725800Medicaid
ID5308810001Medicare NSC