1295748457 NPI number — CEDAR MOUNTAIN MEDICAL INC.

Table of content: (NPI 1295748457)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295748457 NPI number — CEDAR MOUNTAIN MEDICAL INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CEDAR MOUNTAIN MEDICAL 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:
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:
1295748457
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3250
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POST FALLS
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83877-3250
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-777-9199
Provider Business Mailing Address Fax Number:
208-777-8580

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
503 E SELTICE WAY STE 8
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POST FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83854-6499
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-777-9199
Provider Business Practice Location Address Fax Number:
208-777-8580
Provider Enumeration Date:
08/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
208-777-9199

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 806797600 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0144814 . This is a "WA DEPT OF LABOR" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 000010014605 . This is a "BLUE SHIELD OF ID" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 001274700 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9048430 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 03566 . This is a "BLUE CROSS OF IDAHO, GA," identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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