Basic Information
| Provider Information | |||||||||
| NPI: | 1073787784 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MINIDOKA MEMORIAL HOSPITAL CRNA GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1224 8TH ST | ||||||||
| Address2: | |||||||||
| City: | RUPERT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833501527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084360481 | ||||||||
| FaxNumber: | 2084348675 | ||||||||
| Practice Location | |||||||||
| Address1: | 1224 8TH ST | ||||||||
| Address2: | |||||||||
| City: | RUPERT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833501527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084360481 | ||||||||
| FaxNumber: | 2084348675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2008 | ||||||||
| LastUpdateDate: | 10/03/2011 | ||||||||
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| AuthorizedOfficialLastName: | HANSEN | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2084360481 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MINIDOKA MEMORIAL HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 002336000 | 01 | BLUE SHIELD | OTHER | M8068633 | 05 | ID | MEDICAID | 00166 | 01 | BLUE CROSS OF IDAHO | OTHER |