Provider Demographics
NPI:1649410218
Name:BOISE LASER AND COSMETIC SURGERY CENTER PC
Entity Type:Organization
Organization Name:BOISE LASER AND COSMETIC SURGERY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BRET
Authorized Official - Middle Name:J
Authorized Official - Last Name:RODGERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-939-9000
Mailing Address - Street 1:6077 N EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-0997
Mailing Address - Country:US
Mailing Address - Phone:208-939-9000
Mailing Address - Fax:208-939-9580
Practice Address - Street 1:6077 N EAGLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-0997
Practice Address - Country:US
Practice Address - Phone:208-939-9000
Practice Address - Fax:208-939-9580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-23
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806174700Medicaid
ID806174700Medicaid
ID1101650Medicare PIN