Provider Demographics
NPI:1871016071
Name:PORTNEUF ASC, LLC
Entity Type:Organization
Organization Name:PORTNEUF ASC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVP
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:PETROVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-296-3000
Mailing Address - Street 1:1 BURTON HILLS BLVD STE 250
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-6195
Mailing Address - Country:US
Mailing Address - Phone:615-296-3000
Mailing Address - Fax:615-296-6227
Practice Address - Street 1:1151 HOSPITAL WAY BLDG A
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5091
Practice Address - Country:US
Practice Address - Phone:208-232-6616
Practice Address - Fax:208-232-6618
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:POCATELLO HEALTH SYSTEM, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-07-19
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical