Provider Demographics
NPI:1992898605
Name:ST BENEDICTS FAMILY MEDICAL CENTER
Entity type:Organization
Organization Name:ST BENEDICTS FAMILY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:STEVENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-324-0425
Mailing Address - Street 1:709 N LINCOLN
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338
Mailing Address - Country:US
Mailing Address - Phone:208-324-4301
Mailing Address - Fax:208-324-3878
Practice Address - Street 1:414 N LINCOLN
Practice Address - Street 2:SUITE 1
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338
Practice Address - Country:US
Practice Address - Phone:208-324-0526
Practice Address - Fax:208-324-4809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDHH174251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010033877OtherBLUE SHIELD OF IDAHO
ID00288500Medicaid
ID01701OtherBLUE CROSS OF IDAHO
ID000010033877OtherBLUE SHIELD OF IDAHO