Provider Demographics
NPI:1770680191
Name:CHAMBERLAIN GENERAL SURGERY PA
Entity Type:Organization
Organization Name:CHAMBERLAIN GENERAL SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:CHAMBERLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-528-6500
Mailing Address - Street 1:4800 E MAJESTIC VW
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83406-8179
Mailing Address - Country:US
Mailing Address - Phone:208-528-6500
Mailing Address - Fax:208-525-6151
Practice Address - Street 1:2805 VALENCIA DRIVE
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:208-528-6500
Practice Address - Fax:208-525-6151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-194208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1302001Medicare ID - Type UnspecifiedGROUP PRICING NUMBER