1073562591 NPI number — BONNER GENERAL HOSPITAL, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073562591 NPI number — BONNER GENERAL HOSPITAL, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BONNER GENERAL HOSPITAL, INC.
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:
Provider Other Organization Name Type Code:
6
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:
1073562591
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1353
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANDPOINT
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83864-0863
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-265-1179
Provider Business Mailing Address Fax Number:
208-265-1085

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
520 N 3RD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANDPOINT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83864-1507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-265-1179
Provider Business Practice Location Address Fax Number:
208-265-1085
Provider Enumeration Date:
05/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HENNESSY
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER BONNER GENE
Authorized Official Telephone Number:
208-263-1441

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 002274200 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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