Provider Demographics
NPI:1518021849
Name:IDAHO EYE CENTER PA
Entity type:Organization
Organization Name:IDAHO EYE CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:P
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-524-2025
Mailing Address - Street 1:2025 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404
Mailing Address - Country:US
Mailing Address - Phone:208-524-2025
Mailing Address - Fax:208-529-1924
Practice Address - Street 1:2025 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-524-2025
Practice Address - Fax:208-529-1924
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IDAHO EYE CENTER, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-21
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8C626OtherBLUE CROSS
ID8F876OtherBLUE CROSS
ID8E837OtherBLUE CROSS
ID84434OtherBLUE CROSS
ID84434OtherBLUE CROSS
ID1373828Medicare ID - Type Unspecified
ID8C626OtherBLUE CROSS
ID8F876OtherBLUE CROSS
WY10006Medicare ID - Type Unspecified