Provider Demographics
NPI:1427293521
Name:BOISE INTENSIVE CARE HOSPITAL INC
Entity type:Organization
Organization Name:BOISE INTENSIVE CARE HOSPITAL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:CRONIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-241-2128
Mailing Address - Street 1:5340 LEGACY DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-3178
Mailing Address - Country:US
Mailing Address - Phone:469-241-2100
Mailing Address - Fax:469-241-2177
Practice Address - Street 1:2131 S BONITO WAY
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1659
Practice Address - Country:US
Practice Address - Phone:877-801-2244
Practice Address - Fax:208-489-9599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-04
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID69208M00000X, 282E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282E00000XHospitalsLong Term Care Hospital
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808282500Medicaid
ID1369006OtherMEDICARE - B
ID808282500Medicaid