Basic Information
| Provider Information | |||||||||
| NPI: | 1134173115 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EASTERN IDAHO HEALTH SERVICES, INC. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EASTERN IDAHO REGIONAL MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 CHANNING WAY | ||||||||
| Address2: | P.O. BOX 2077 | ||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834047533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085296111 | ||||||||
| FaxNumber: | 2085297021 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 CHANNING WAY | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834047533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085296111 | ||||||||
| FaxNumber: | 2085297021 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 06/11/2010 | ||||||||
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| AuthorizedOfficialLastName: | BAIOCCO | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2085296111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | XHSP41065 | 05 | CA | MEDICAID |