Provider Demographics
NPI:1629145685
Name:IDAHO EYE CENTER PA
Entity Type:Organization
Organization Name:IDAHO EYE CENTER PA
Other - Org Name:IDAHO EYE SURGICENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:P
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-524-2025
Mailing Address - Street 1:2025 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404
Mailing Address - Country:US
Mailing Address - Phone:208-524-2025
Mailing Address - Fax:208-529-1924
Practice Address - Street 1:2025 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-524-2025
Practice Address - Fax:208-529-1924
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IDAHO EYE CENTER PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-28
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID490000614OtherRAILROAD MEDICARE
ID480000614OtherRAILROAD MEDICARE
ID00984OtherBLUE CROSS
ID002562201Medicaid
ID002565200Medicaid
ID105947500OtherWYOMING MEDICAID
ID5207OtherBLUE CROSS
ID1870064Medicare ID - Type Unspecified
ID1870282Medicare ID - Type Unspecified