Basic Information
| Provider Information | |||||||||
| NPI: | 1073834529 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOUNTAIN VIEW HOSPITAL PHYSICIAN ORGANIZATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2325 CORONADO ST | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085572700 | ||||||||
| FaxNumber: | 2085572701 | ||||||||
| Practice Location | |||||||||
| Address1: | 2325 CORONADO ST | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085572700 | ||||||||
| FaxNumber: | 2085572701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2010 | ||||||||
| LastUpdateDate: | 06/18/2010 | ||||||||
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| AuthorizedOfficialLastName: | ROSSI | ||||||||
| AuthorizedOfficialFirstName: | EVELYN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF PATIENT FINANACIA | ||||||||
| AuthorizedOfficialTelephone: | 2085572716 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 64 | ID | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 806528800 | 05 | ID | MEDICAID |