Provider Demographics
NPI:1659380269
Name:SPINE INSTITUTE OF IDAHO P A
Entity Type:Organization
Organization Name:SPINE INSTITUTE OF IDAHO P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ASST ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-855-2900
Mailing Address - Street 1:360 E MONTVUE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6318
Mailing Address - Country:US
Mailing Address - Phone:208-855-2900
Mailing Address - Fax:208-898-9877
Practice Address - Street 1:360 E MONTVUE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6318
Practice Address - Country:US
Practice Address - Phone:208-855-2900
Practice Address - Fax:208-898-9877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805983000Medicaid
ID5045100001Medicare NSC
ID805983000Medicaid
ID1377628Medicare PIN
IDCJ6135Medicare PIN