Basic Information
| Provider Information | |||||||||
| NPI: | 1790182590 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRITMAN MEDICAL CENTER INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GRITMAN INTERNAL MEDICINE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MOSCOW | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838433056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088824511 | ||||||||
| FaxNumber: | 2088836580 | ||||||||
| Practice Location | |||||||||
| Address1: | 804 S WASHINGTON ST STE A | ||||||||
| Address2: | |||||||||
| City: | MOSCOW | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838433182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088831152 | ||||||||
| FaxNumber: | 2088821486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2014 | ||||||||
| LastUpdateDate: | 12/04/2015 | ||||||||
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| AuthorizedOfficialLastName: | BECKER | ||||||||
| AuthorizedOfficialFirstName: | PRESTON | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2088832221 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GRITMAN MEDICAL CENTER INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 39 | ID | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.