Basic Information
| Provider Information | |||||||||
| NPI: | 1417210568 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PORTNEUF MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1593 POINTVIEW DR | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832012800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082410651 | ||||||||
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| Practice Location | |||||||||
| Address1: | 777 HOSPITAL WAY | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832015175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082392260 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2012 | ||||||||
| LastUpdateDate: | 06/22/2012 | ||||||||
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| AuthorizedOfficialLastName: | STEPHENS | ||||||||
| AuthorizedOfficialFirstName: | NORMAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2082391004 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 24374A | ID | Y | Hospitals | General Acute Care Hospital | Critical Access |
No ID Information.