1821091083 NPI number — WALTER KNOX MEMORIAL HOSPITAL

Table of content: (NPI 1821091083)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821091083 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:
VALOR HEALTH - EMMETT MEDICAL CENTER
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:
1821091083
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1102 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:
83617-2713
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-365-6004
Provider Business Mailing Address Fax Number:
208-365-3589

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1102 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:
83617-2713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-365-6004
Provider Business Practice Location Address Fax Number:
208-365-3589
Provider Enumeration Date:
05/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
TURPEN
Authorized Official First Name:
BRAD
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
208-999-3870

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , with the licence number:  13-8525 , 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: 13-8525 . This is a "RURAL HEALTH CLINIC PTAN" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8E001 . This is a "BLUE CROSS OF IDAHO GROUP" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 805187500 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 138525 . This is a "UNSPECIFIED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 002563400 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 002563800 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 138525 . This is a "MEDICARE PTAN" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 806367900 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 807437800 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000010006204 . This is a "REGENCE BLUE SH OF ID GRP" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000269700 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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