Provider Demographics
NPI:1821459496
Name:GEM STATE ENDOSCOPY
Entity Type:Organization
Organization Name:GEM STATE ENDOSCOPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLEVINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-298-2135
Mailing Address - Street 1:2517 17TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-6311
Mailing Address - Country:US
Mailing Address - Phone:208-743-4373
Mailing Address - Fax:208-743-3369
Practice Address - Street 1:3709 14TH STREET
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501
Practice Address - Country:US
Practice Address - Phone:208-743-4373
Practice Address - Fax:208-743-3369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-10
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical