Provider Demographics
NPI:1023267895
Name:EAST FALLS PLASTIC SURGERY LLC
Entity type:Organization
Organization Name:EAST FALLS PLASTIC SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:KANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-568-5933
Mailing Address - Street 1:2860 CHANNING WAY
Mailing Address - Street 2:SUITE 114A
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7531
Mailing Address - Country:US
Mailing Address - Phone:208-535-4565
Mailing Address - Fax:208-535-4564
Practice Address - Street 1:2860 CHANNING WAY
Practice Address - Street 2:SUITE 114A
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7531
Practice Address - Country:US
Practice Address - Phone:208-535-4565
Practice Address - Fax:208-535-4564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-16
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1023267895Medicaid
ID1023267895Medicaid
MT1023267895Medicaid
ID808218000Medicaid
ID1370117Medicare PIN
MT1023267895Medicaid