Provider Demographics
NPI:1912992900
Name:BOISE ENDOSCOPY CENTER, LLC
Entity Type:Organization
Organization Name:BOISE ENDOSCOPY CENTER, LLC
Other - Org Name:DBA MERIDIAN ENDOSCOPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:PAHSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-489-1431
Mailing Address - Street 1:425 W BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6035
Mailing Address - Country:US
Mailing Address - Phone:208-343-1702
Mailing Address - Fax:208-342-7042
Practice Address - Street 1:2235 E GALA ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7090
Practice Address - Country:US
Practice Address - Phone:208-695-2100
Practice Address - Fax:208-695-2110
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOISE ENDOSCOPY CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-15
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID13-C0001057261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1870273Medicare PIN