Provider Demographics
NPI:1992789101
Name:STATE OF IDAHO DEPARTMENT OF HEALTH AND WELFARE
Entity type:Organization
Organization Name:STATE OF IDAHO DEPARTMENT OF HEALTH AND WELFARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HOSPITAL ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:G
Authorized Official - Last Name:SESSIONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-785-8402
Mailing Address - Street 1:700 E ALICE ST
Mailing Address - Street 2:PO BOX 400
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-4925
Mailing Address - Country:US
Mailing Address - Phone:208-785-1200
Mailing Address - Fax:208-785-8518
Practice Address - Street 1:700 EAST ALICE
Practice Address - Street 2:BOX 400
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221
Practice Address - Country:US
Practice Address - Phone:208-785-1200
Practice Address - Fax:208-785-8518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-01
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID#17283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID00844OtherBLUE CROSS OF IDAHO
ID002821500Medicaid
ID20315OtherREGENCE BLUE SHIELD OF ID
ID1257832Medicare ID - Type UnspecifiedPART B
ID002821500Medicaid