Basic Information
| Provider Information | |||||||||
| NPI: | 1225202922 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MINIDOKA MEMORIAL HOSPITAL AMBULANCE | ||||||||
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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: | 06/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | HANSEN | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| 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 | 3416L0300X | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 7808 | 01 | BLUE SHIELD OF IDAHO | OTHER | E0922 | 01 | BLUE CROSS OF IDAHO | OTHER | M0023360 | 05 | ID | MEDICAID |