Provider Demographics
NPI:1811035090
Name:HUNTSMAN ORTHOPAEDIC SURGERY & SPORTS MEDICINEPA
Entity Type:Organization
Organization Name:HUNTSMAN ORTHOPAEDIC SURGERY & SPORTS MEDICINEPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:I
Authorized Official - Last Name:HUNTSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-522-6662
Mailing Address - Street 1:3300 WASHINGTON PARKWAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7592
Mailing Address - Country:US
Mailing Address - Phone:208-522-6662
Mailing Address - Fax:208-522-0880
Practice Address - Street 1:3300 WASHINGTON PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7592
Practice Address - Country:US
Practice Address - Phone:208-522-6662
Practice Address - Fax:208-522-0880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8232207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010033201OtherMEDIVANTAGE BS
ID264199OtherALTIUS
ID0000100033201OtherBLUE SHIELD
ID0543918OtherCONSULTEC INC
MN028X3HUOtherBX MINNESOTA
ID43166OtherANTHEM
ID43166OtherBLUE CROSS IDAHO HMO
ID43166OtherANTHEM
ID0000100033201OtherBLUE SHIELD
ID000010033201OtherMEDIVANTAGE BS
MN028X3HUOtherBX MINNESOTA