Provider Demographics
NPI:1740580794
Name:BLACKFOOT MEDICAL CLINIC SURGEONS
Entity Type:Organization
Organization Name:BLACKFOOT MEDICAL CLINIC SURGEONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:CASPERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-785-2600
Mailing Address - Street 1:1441 PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1667
Mailing Address - Country:US
Mailing Address - Phone:208-785-2600
Mailing Address - Fax:
Practice Address - Street 1:1441 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1667
Practice Address - Country:US
Practice Address - Phone:208-785-2600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLACKFOOT MEDICAL CLINIC INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty