Provider Demographics
NPI:1871648352
Name:BOISE SURGICAL GROUP
Entity Type:Organization
Organization Name:BOISE SURGICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRUNZKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-364-3000
Mailing Address - Street 1:3399 E. LOUISE DR.
Mailing Address - Street 2:#400
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-364-3000
Mailing Address - Fax:208-364-3191
Practice Address - Street 1:3399 E. LOUISE DR.
Practice Address - Street 2:#400
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-364-3000
Practice Address - Fax:208-364-3191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7481208600000X
IDM8489208600000X
IDM7975208600000X
IDM8195208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDCI1633OtherRAILROAD MEDICARE
ID002354900Medicaid
IDCI1633OtherRAILROAD MEDICARE
H15703Medicare UPIN
IDH63779Medicare UPIN
ID002354900Medicaid
IDF60222Medicare UPIN
IDB63907Medicare UPIN
IDH41881Medicare UPIN