Provider Demographics
NPI:1821334657
Name:SURGICAL SPECIALTIES CLINIC
Entity Type:Organization
Organization Name:SURGICAL SPECIALTIES CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:TURPEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-999-3870
Mailing Address - Street 1:1202 E LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-2715
Mailing Address - Country:US
Mailing Address - Phone:208-365-2338
Mailing Address - Fax:
Practice Address - Street 1:1024 E LOCUST ST
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-2776
Practice Address - Country:US
Practice Address - Phone:208-365-2338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALTER KNOX MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-12-26
Last Update Date:2019-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-0674208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO65836Medicare UPIN