Basic Information
| Provider Information | |||||||||
| NPI: | 1114151016 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. MARY'S HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST. MARY'S HOSPITAL PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 137 | ||||||||
| Address2: | |||||||||
| City: | COTTONWOOD | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835220137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089623251 | ||||||||
| FaxNumber: | 2089622323 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 LEWISTON STREET | ||||||||
| Address2: | |||||||||
| City: | COTTONWOOD | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835229750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089623251 | ||||||||
| FaxNumber: | 2089622323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2009 | ||||||||
| LastUpdateDate: | 04/07/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | UPTMOR | ||||||||
| AuthorizedOfficialFirstName: | THERESA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF BUSINESS SERVICES OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2089622301 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.