Basic Information
| Provider Information | |||||||||
| NPI: | 1487272399 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHOSHONE MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 JACOBS GULCH RD | ||||||||
| Address2: | |||||||||
| City: | KELLOGG | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838372023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087841228 | ||||||||
| FaxNumber: | 2087861019 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 JACOBS GULCH RD | ||||||||
| Address2: | |||||||||
| City: | KELLOGG | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838372023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087844612 | ||||||||
| FaxNumber: | 2087861019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2020 | ||||||||
| LastUpdateDate: | 04/27/2021 | ||||||||
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| AuthorizedOfficialLastName: | ERDMAN | ||||||||
| AuthorizedOfficialFirstName: | DONJA | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2087841221 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SHOSHONE MEDICAL CENTER | ||||||||
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| NPICertificationDate: | 04/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.