Basic Information
| Provider Information | |||||||||
| NPI: | 1417122821 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELMORE MEDICAL CENTER SPECIALTY PHYSICIAN GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1270 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836471270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085878401 | ||||||||
| FaxNumber: | 2085878406 | ||||||||
| Practice Location | |||||||||
| Address1: | 890 N 6TH E | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836472206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085878401 | ||||||||
| FaxNumber: | 2085878406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2008 | ||||||||
| LastUpdateDate: | 05/28/2009 | ||||||||
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| AuthorizedOfficialLastName: | JANOUSEK | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2085878401 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ELMORE MEDICAL CENTER HOSPITAL DISTRICT | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 000010149755 | 01 | ID | BLUE SHIELD PROF NUMBER | OTHER | 000014148578 | 01 | ID | BLUE SHIELD | OTHER | 002860700 | 05 | ID | MEDICAID | 8K594 | 01 | ID | BLUE CROSS | OTHER |