Provider Demographics
NPI:1972179208
Name:IDAHO OTOLOGIC SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:IDAHO OTOLOGIC SURGERY CENTER, LLC
Other - Org Name:SYRINGA OUTPATIENT SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-278-4304
Mailing Address - Street 1:13900 W WAINWRIGHT DR STE 102
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-5028
Mailing Address - Country:US
Mailing Address - Phone:480-455-2769
Mailing Address - Fax:208-963-3270
Practice Address - Street 1:1209 N SUMMERBROOK AVE STE 110
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8760
Practice Address - Country:US
Practice Address - Phone:208-938-5823
Practice Address - Fax:208-963-3270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-27
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical