Provider Demographics
NPI:1962625764
Name:ID DEPT OF HEALTH & WELFARE CSHP (HD1)
Entity type:Organization
Organization Name:ID DEPT OF HEALTH & WELFARE CSHP (HD1)
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACTING PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAIGE
Authorized Official - Middle Name:
Authorized Official - Last Name:FINCHER
Authorized Official - Suffix:
Authorized Official - Credentials:BSW
Authorized Official - Phone:208-334-4935
Mailing Address - Street 1:PO BOX 83720
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83720-0036
Mailing Address - Country:US
Mailing Address - Phone:208-334-4935
Mailing Address - Fax:208-332-7307
Practice Address - Street 1:8500 N ATLAS RD
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8332
Practice Address - Country:US
Practice Address - Phone:208-415-5136
Practice Address - Fax:208-415-5131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0024706Medicaid
ID000010022948OtherBLUE SHIELD
IDHW207OtherBLUE CROSS OF ID