Basic Information
| Provider Information | |||||||||
| NPI: | 1437732492 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRITMAN MEDICAL CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8007 | ||||||||
| Address2: | |||||||||
| City: | MOSCOW | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838430507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088824511 | ||||||||
| FaxNumber: | 2088836580 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 W A ST STE G | ||||||||
| Address2: | |||||||||
| City: | MOSCOW | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838434902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088824511 | ||||||||
| FaxNumber: | 2088836580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2021 | ||||||||
| LastUpdateDate: | 04/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | LYNAS | ||||||||
| AuthorizedOfficialFirstName: | DANIELLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2088832220 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.