1912555319 NPI number — MOUNT CARMEL HEALTH PLAN OF IDAHO, INC.

Table of content: (NPI 1912555319)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912555319 NPI number — MOUNT CARMEL HEALTH PLAN OF IDAHO, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUNT CARMEL HEALTH PLAN OF IDAHO, 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:
1912555319
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6150 E BROAD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43213-1574
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-546-4651
Provider Business Mailing Address Fax Number:
614-546-4106

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3100 EASTON SQUARE PLACE
Provider Second Line Business Practice Location Address:
SUITE 300 - HEALTH PLAN
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-546-4651
Provider Business Practice Location Address Fax Number:
614-546-4106
Provider Enumeration Date:
08/28/2019

Additional Information

Authorized Official

Authorized Official Last Name:
WHETSTONE
Authorized Official First Name:
TRISHA
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSOCIATE COUNSEL
Authorized Official Telephone Number:
614-546-4651

Provider Taxonomy Codes

  • Taxonomy code: 302R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 305R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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