Basic Information
| Provider Information | |||||||||
| NPI: | 1265442388 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCCALL MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MCCALL THERAPY SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 STATE ST | ||||||||
| Address2: | |||||||||
| City: | MCCALL | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836383704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086342221 | ||||||||
| FaxNumber: | 2086347112 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 STATE STREET | ||||||||
| Address2: | |||||||||
| City: | MCCALL | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836383704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086342221 | ||||||||
| FaxNumber: | 2086347112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 05/06/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GROENIG | ||||||||
| AuthorizedOfficialFirstName: | MATT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2086342221 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MCCALL MEMORIAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC0050X | 11 | ID | Y | Ambulatory Health Care Facilities | Clinic/Center | Critical Access Hospital |
ID Information
| ID | Type | State | Issuer | Description | 807424900 | 05 | ID | MEDICAID | 000010147637 | 01 | ID | REGENCE CLINIC GRP # | OTHER | 8J612 | 01 | ID | BLUE CROSS CLINIC GRP # | OTHER | 806937700 | 05 | ID | MEDICAID |