Provider Demographics
NPI:1255520037
Name:IDAHO PAIN CENTER AND ANESTHESIA PC
Entity type:Organization
Organization Name:IDAHO PAIN CENTER AND ANESTHESIA PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BEDELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-755-0964
Mailing Address - Street 1:286 N GATEWAY DR
Mailing Address - Street 2:STE 201
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-5602
Mailing Address - Country:US
Mailing Address - Phone:435-755-9174
Mailing Address - Fax:
Practice Address - Street 1:286 N GATEWAY DR
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-9733
Practice Address - Country:US
Practice Address - Phone:435-755-9184
Practice Address - Fax:435-755-9148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT329116-1204208VP0014X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000011881Medicare PIN