Provider Demographics
NPI:1992834089
Name:STEPHEN R MARANO MD PC
Entity Type:Organization
Organization Name:STEPHEN R MARANO MD PC
Other - Org Name:EASTERN IDAHO NEUROLOGICAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MARANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-522-6930
Mailing Address - Street 1:2375 E SUNNYSIDE RD
Mailing Address - Street 2:STE F
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7579
Mailing Address - Country:US
Mailing Address - Phone:208-522-6930
Mailing Address - Fax:208-523-5342
Practice Address - Street 1:2375 E SUNNYSIDE RD
Practice Address - Street 2:STE F
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7579
Practice Address - Country:US
Practice Address - Phone:208-522-6930
Practice Address - Fax:208-523-5342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5076207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
185584800OtherASC
ID57489OtherBLUE CROSS
ID000060000Medicaid
ID000010002012OtherBLUE SHIELD
185584800OtherASC
ID000010002012OtherBLUE SHIELD