Provider Demographics
NPI:1184899973
Name:IDAHO CLEFT AND CRANIOFACIAL PEDIATRIC PLASTIC SURGERY, P.A.
Entity type:Organization
Organization Name:IDAHO CLEFT AND CRANIOFACIAL PEDIATRIC PLASTIC SURGERY, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:H
Authorized Official - Last Name:GRIFFITHS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-433-1736
Mailing Address - Street 1:100 E IDAHO STREET, SUITE 303
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6269
Mailing Address - Country:US
Mailing Address - Phone:208-433-1736
Mailing Address - Fax:208-433-1738
Practice Address - Street 1:100 E IDAHO STREET, SUITE 303
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6269
Practice Address - Country:US
Practice Address - Phone:208-433-1736
Practice Address - Fax:208-433-1738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7454208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805132700Medicaid