Provider Demographics
NPI:1952414609
Name:ADDISON SURGERY CENTER INC
Entity Type:Organization
Organization Name:ADDISON SURGERY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLACKMER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:208-734-8441
Mailing Address - Street 1:PO BOX 16820
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83715-6820
Mailing Address - Country:US
Mailing Address - Phone:208-734-8441
Mailing Address - Fax:208-734-5993
Practice Address - Street 1:191 ADDISON AVE
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5177
Practice Address - Country:US
Practice Address - Phone:208-734-8441
Practice Address - Fax:208-734-5993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP 118261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID=========OtherTAX I.D. NUMBER