1063419018 NPI number — WALTER KNOX MEMORIAL HOSPITAL

Table of content: (NPI 1063419018)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063419018 NPI number — WALTER KNOX MEMORIAL HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALTER KNOX 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:
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:
1063419018
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1202 E LOCUST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EMMETT
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83617-2715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-365-3561
Provider Business Mailing Address Fax Number:
208-365-4176

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1202 E LOCUST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EMMETT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83617-2715
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-365-3561
Provider Business Practice Location Address Fax Number:
208-365-4176
Provider Enumeration Date:
07/06/2005

Additional Information

Authorized Official

Authorized Official Last Name:
STAMPFLI
Authorized Official First Name:
PAM
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
208-901-3213

Provider Taxonomy Codes

  • Taxonomy code: 282NC0060X , with the licence number:  07 , 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: 000010005890 . This is a "REGENCE BS HOSPITAL" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 002811000 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 002811100 . This is a "MEDICAID DR. PROVIDER #" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 002811500 . This is a "MEDICAID ANESTHESIA PROV#" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: XHSP40645 . This is a "MEDICAID CA OUT PATIENT" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 000010005891 . This is a "REGENCE BS PROFESSIONAL" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 002811200 . This is a "MEDICAID PHARMACY PROV #" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 0101300227002 . This is a "MEDICAID KENTUCKY" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 8K446 . This is a "BLUE CROSS PROFESSIONAL" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: XHSP30645 . This is a "MEDICAID CA IN PATIENT" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00091 . This is a "BC HOSPITAL PROV #" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 109654 . This is a "MEDICAID ARIZONA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 4103426 . This is a "MEDICAID MONTANA" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 1252002 . This is a "MEDICARE PROF. FEE PROV #" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 805213700 . This is a "MEDICAID ER ROOM PHYSICIA" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 95002960 . This is a "MEDICAID COLORADO" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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