Provider Demographics
NPI:1023228558
Name:BOISE GASTROENTEROLOGY ASSOCIATES
Entity type:Organization
Organization Name:BOISE GASTROENTEROLOGY ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:F
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-489-1900
Mailing Address - Street 1:6259 W EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8731
Mailing Address - Country:US
Mailing Address - Phone:208-489-1900
Mailing Address - Fax:208-375-5286
Practice Address - Street 1:6259 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8731
Practice Address - Country:US
Practice Address - Phone:208-489-1900
Practice Address - Fax:208-375-5286
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOISE GASTROENTEROLOGY ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-23
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1870119Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER