Provider Demographics
NPI:1487272399
Name:SHOSHONE MEDICAL CENTER
Entity type:Organization
Organization Name:SHOSHONE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DONJA
Authorized Official - Middle Name:C
Authorized Official - Last Name:ERDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-784-1221
Mailing Address - Street 1:25 JACOBS GULCH RD
Mailing Address - Street 2:
Mailing Address - City:KELLOGG
Mailing Address - State:ID
Mailing Address - Zip Code:83837-2023
Mailing Address - Country:US
Mailing Address - Phone:208-784-1228
Mailing Address - Fax:208-786-1019
Practice Address - Street 1:25 JACOBS GULCH RD
Practice Address - Street 2:
Practice Address - City:KELLOGG
Practice Address - State:ID
Practice Address - Zip Code:83837-2023
Practice Address - Country:US
Practice Address - Phone:208-784-4612
Practice Address - Fax:208-786-1019
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHOSHONE MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-07-07
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty