Basic Information
Provider Information | |||||||||
NPI: | 1225082209 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EASTERN IDAHO HEALTH SERVICES INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | EASTERN IDAHO REGIONAL MEDICAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 06/01/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BAIOCCO | ||||||||
AuthorizedOfficialFirstName: | JEFFREY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 2085296111 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/01/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X |   |   | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 0414336 | 05 | MT |   | MEDICAID | 1188039 | 05 | NV |   | MEDICAID | 3020989 | 05 | WA |   | MEDICAID | HS848IP | 05 | AK |   | MEDICAID | 022575 | 05 | AZ |   | MEDICAID | 114794300 | 05 | WY |   | MEDICAID | 2614200 | 05 | ID |   | MEDICAID | XHSP31065 | 05 | CA |   | MEDICAID | 000010006678 | 01 | ID | BLUE SHIELD | OTHER | 00315 | 01 | ID | BLUE CROSS | OTHER | 091843 | 05 | OR |   | MEDICAID |