1992789101 NPI number — STATE OF IDAHO DEPARTMENT OF HEALTH AND WELFARE

Table of content: (NPI 1992789101)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992789101 NPI number — STATE OF IDAHO DEPARTMENT OF HEALTH AND WELFARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE OF IDAHO DEPARTMENT OF HEALTH AND WELFARE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
STATE HOSPITAL SOUTH
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992789101
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 E ALICE ST
Provider Second Line Business Mailing Address:
PO BOX 400
Provider Business Mailing Address City Name:
BLACKFOOT
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83221-4925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-785-1200
Provider Business Mailing Address Fax Number:
208-785-8518

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 EAST ALICE
Provider Second Line Business Practice Location Address:
BOX 400
Provider Business Practice Location Address City Name:
BLACKFOOT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-785-1200
Provider Business Practice Location Address Fax Number:
208-785-8518
Provider Enumeration Date:
12/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SESSIONS
Authorized Official First Name:
TRACEY
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
HOSPITAL ADMINISTRATOR
Authorized Official Telephone Number:
208-785-8402

Provider Taxonomy Codes

  • Taxonomy code: 283Q00000X , with the licence number:  #17 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00844 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 002821500 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20315 . This is a "REGENCE BLUE SHIELD OF ID" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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