Basic Information
Provider Information | |||||||||
NPI: | 1134333495 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MINIDOKA MEMORIAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MMH PHYSICIANS | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1224 8TH ST | ||||||||
Address2: |   | ||||||||
City: | RUPERT | ||||||||
State: | ID | ||||||||
PostalCode: | 833501527 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2084360481 | ||||||||
FaxNumber: | 2084366038 | ||||||||
Practice Location | |||||||||
Address1: | 1224 8TH ST | ||||||||
Address2: |   | ||||||||
City: | RUPERT | ||||||||
State: | ID | ||||||||
PostalCode: | 833501527 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2084360481 | ||||||||
FaxNumber: | 2084366038 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/09/2007 | ||||||||
LastUpdateDate: | 12/09/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MURPHY | ||||||||
AuthorizedOfficialFirstName: | THOMAS | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 2084360481 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MINIDOKA MEMORIAL HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0002X | 26 | ID | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care |
ID Information
ID | Type | State | Issuer | Description | M0023361 | 05 | ID |   | MEDICAID | 00010006547 | 01 | ID | BLUE SHIELD ER | OTHER | 8D418 | 01 | ID | BLUE CROSS ER | OTHER |