Provider Demographics
NPI:1336240670
Name:SOUTHERN IDAHO PAIN INSTITUTE P.C.
Entity Type:Organization
Organization Name:SOUTHERN IDAHO PAIN INSTITUTE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ANESTHESIOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:L
Authorized Official - Last Name:DILLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-733-3181
Mailing Address - Street 1:236 MARTIN ST.
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301
Mailing Address - Country:US
Mailing Address - Phone:208-733-3181
Mailing Address - Fax:208-733-3168
Practice Address - Street 1:236 MARTIN ST.
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301
Practice Address - Country:US
Practice Address - Phone:208-733-3181
Practice Address - Fax:208-733-3168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7113261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID03384OtherBLUE CROSS ASC#
ID000010006663OtherREGENCE ASC #
ID804229000Medicaid
ID03384OtherBLUE CROSS ASC#
ID1870113Medicare PIN