Provider Demographics
NPI:1699057166
Name:BEAR LAKE COUNTY MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:BEAR LAKE COUNTY MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PATSY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOEHME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-847-4410
Mailing Address - Street 1:465 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:ID
Mailing Address - Zip Code:83254-1544
Mailing Address - Country:US
Mailing Address - Phone:208-847-4495
Mailing Address - Fax:208-847-4336
Practice Address - Street 1:465 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:ID
Practice Address - Zip Code:83254-1544
Practice Address - Country:US
Practice Address - Phone:208-847-4495
Practice Address - Fax:208-847-4336
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEAR LAKE COUNTY MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-09-12
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID138514Medicare Oscar/Certification