Provider Demographics
NPI:1750337978
Name:PEDIATRIC NEUROSURGRY OF IDAHO PC
Entity type:Organization
Organization Name:PEDIATRIC NEUROSURGRY OF IDAHO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:CHERNY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-381-7360
Mailing Address - Street 1:6140 CURTISIAN AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8880
Mailing Address - Country:US
Mailing Address - Phone:208-367-3500
Mailing Address - Fax:208-367-3500
Practice Address - Street 1:100 E IDAHO ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6270
Practice Address - Country:US
Practice Address - Phone:208-381-7360
Practice Address - Fax:208-381-7361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2008-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8385207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
8M819OtherBLUE CROSS OF IDAHO GROUP
1105227Medicare PIN
G04644Medicare UPIN
P00016671Medicare PIN