Basic Information
| Provider Information | |||||||||
| NPI: | 1902841893 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IDAHO PHYSICIAN SERVICES INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EAST FALLS ORTHOPEDICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 HEALTH PARK DR | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370274525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153737600 | ||||||||
| FaxNumber: | 8663461426 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 CHANNING WAY STE A205 | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834047586 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085354580 | ||||||||
| FaxNumber: | 2085354520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 10/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | TEDRICK | ||||||||
| AuthorizedOfficialTitleorPosition: | GROUP VP/AO | ||||||||
| AuthorizedOfficialTelephone: | 6153723375 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1902841893 | 05 | WY | MEDICAID | 807418100 | 05 | ID | MEDICAID | 000010154957 | 01 | ID | BLUE SHIELD | OTHER | 1902841893 | 05 | MT | MEDICAID | 8M826 | 01 | ID | BLUECROSS OF ID | OTHER |