Provider Demographics
NPI:1831368752
Name:SHOULDER & KNEE CENTER, PA
Entity type:Organization
Organization Name:SHOULDER & KNEE CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDARY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-524-5633
Mailing Address - Street 1:2035 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6430
Mailing Address - Country:US
Mailing Address - Phone:208-524-5633
Mailing Address - Fax:208-524-1045
Practice Address - Street 1:2035 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6430
Practice Address - Country:US
Practice Address - Phone:208-524-5633
Practice Address - Fax:208-524-1045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8490207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP00020270OtherTRAVELERS MEDICARE
ID806411300Medicaid
ID000010139745OtherBLUE SHIELD OF IDAHO
ID806411300Medicaid