Provider Demographics
NPI:1477359909
Name:GRANITE MOUNTAIN SURGERY PLLC
Entity type:Organization
Organization Name:GRANITE MOUNTAIN SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:L
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-412-4530
Mailing Address - Street 1:8950 W EMERALD ST STE 195
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8296
Mailing Address - Country:US
Mailing Address - Phone:208-999-3034
Mailing Address - Fax:
Practice Address - Street 1:8950 W EMERALD ST STE 195
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8296
Practice Address - Country:US
Practice Address - Phone:208-999-3034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-24
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty