Provider Demographics
NPI:1760581409
Name:BOISE SHOULDER CLINIC, PA
Entity Type:Organization
Organization Name:BOISE SHOULDER CLINIC, PA
Other - Org Name:HUMPHREY SHOULDER CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:HUMPHREY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-639-4800
Mailing Address - Street 1:3381 W BAVARIA STREET
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5341
Mailing Address - Country:US
Mailing Address - Phone:208-639-4800
Mailing Address - Fax:208-639-4801
Practice Address - Street 1:3381 W BAVARIA STREET
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-5341
Practice Address - Country:US
Practice Address - Phone:208-639-4800
Practice Address - Fax:208-639-4801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9563207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDI36275Medicare UPIN
ID1370000Medicare ID - Type UnspecifiedMEDICARE NUMBER PENDING