Provider Demographics
NPI:1831265321
Name:PCS ENDOSCOPY SUITE
Entity type:Organization
Organization Name:PCS ENDOSCOPY SUITE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:MANSFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-234-0024
Mailing Address - Street 1:110 VISTA DRIVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4835
Mailing Address - Country:US
Mailing Address - Phone:208-234-0024
Mailing Address - Fax:
Practice Address - Street 1:110 VISTA DRIVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4835
Practice Address - Country:US
Practice Address - Phone:208-234-0024
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1870482Medicare ID - Type UnspecifiedFACILITY PROVIDER NUMBER