Basic Information
| Provider Information | |||||||||
| NPI: | 1265564967 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCCALL MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DONNELLY MEDICAL CLINIC, A MMH PHYSICIAN CLINIC | ||||||||
| 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: | 454 WEST ROSEBERRY RD, SUITE 103 | ||||||||
| Address2: | |||||||||
| City: | DONNELLY | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083254455 | ||||||||
| FaxNumber: | 2083254466 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 02/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | KELLIE | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2086342221 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MCCALL MEMORIAL HOSPITAL | ||||||||
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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 | 000010159605 | 01 | ID | REGENCE CLINIC NUMBER | OTHER | 8M977 | 01 | ID | BLUE CROSS OF ID CLINIC | OTHER |