Provider Demographics
NPI:1780103507
Name:AMBULATORY SURGERY CENTER OF BURLEY, LLC
Entity type:Organization
Organization Name:AMBULATORY SURGERY CENTER OF BURLEY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:R
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-677-8888
Mailing Address - Street 1:1344 HILAND AVE STE E
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-1564
Mailing Address - Country:US
Mailing Address - Phone:208-677-8888
Mailing Address - Fax:208-678-5833
Practice Address - Street 1:1344 HILAND AVE STE E
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-1564
Practice Address - Country:US
Practice Address - Phone:208-677-8888
Practice Address - Fax:208-678-5833
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMBULATORY SURGERY CENTER OF BURLEY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty