1265442388 NPI number — MCCALL MEMORIAL HOSPITAL

Table of content: (NPI 1265442388)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265442388 NPI number — MCCALL MEMORIAL HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MCCALL MEMORIAL HOSPITAL
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:
MCCALL THERAPY SERVICES
Provider Other Organization Name Type Code:
3
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:
1265442388
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCCALL
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83638-3704
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-634-2221
Provider Business Mailing Address Fax Number:
208-634-7112

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 STATE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCCALL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83638-3704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-634-2221
Provider Business Practice Location Address Fax Number:
208-634-7112
Provider Enumeration Date:
08/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GROENIG
Authorized Official First Name:
MATT
Authorized Official Middle Name:
Authorized Official Title or Position:
VP FINANCE
Authorized Official Telephone Number:
208-634-2221

Provider Taxonomy Codes

  • Taxonomy code: 261QC0050X , with the licence number:  11 , 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: 807424900 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000010147637 . This is a "REGENCE CLINIC GRP #" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8J612 . This is a "BLUE CROSS CLINIC GRP #" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 806937700 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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