Basic Information
| Provider Information | |||||||||
| NPI: | 1740287911 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EASTERN IDAHO HEALTH SERVICES INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EASTERN IDAHO REGIONAL MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 CHANNING WAY | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834047533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085296111 | ||||||||
| FaxNumber: | 2085297021 | ||||||||
| Practice Location | |||||||||
| Address1: | 2280 E 25TH ST | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834047542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082272100 | ||||||||
| FaxNumber: | 2082272368 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2005 | ||||||||
| LastUpdateDate: | 09/09/2016 | ||||||||
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| AuthorizedOfficialLastName: | CRABTREE | ||||||||
| AuthorizedOfficialFirstName: | DOUG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2085296210 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EASTERN IDAHO HEALTH SERVICES INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 114794303 | 05 | WY | MEDICAID |