Provider Demographics
NPI:1568633592
Name:ST. MARY'S HOSPITAL
Entity type:Organization
Organization Name:ST. MARY'S HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIR OF BUSINESS SERVICES
Authorized Official - Prefix:MS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:A
Authorized Official - Last Name:UPTMOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-962-2301
Mailing Address - Street 1:PO BOX 565
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:ID
Mailing Address - Zip Code:83522-0565
Mailing Address - Country:US
Mailing Address - Phone:208-962-3267
Mailing Address - Fax:208-962-2313
Practice Address - Street 1:701 LEWISTON STREET
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:ID
Practice Address - Zip Code:83522-0565
Practice Address - Country:US
Practice Address - Phone:208-962-3267
Practice Address - Fax:208-962-2313
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARY'S HOSPITAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-18
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805066400Medicaid