Basic Information
| Provider Information | |||||||||
| NPI: | 1679553531 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MINIDOKA MEMORIAL HOSPITAL | ||||||||
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| 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: | 01/18/2006 | ||||||||
| LastUpdateDate: | 02/24/2017 | ||||||||
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| AuthorizedOfficialLastName: | MURPHY | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2084368141 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 26 | ID | N | Hospital Units | Medicare Defined Swing Bed Unit | 282NC0060X | 26 | ID | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | M0023360 | 05 | ID | MEDICAID | 000010006548 | 01 | ID | BLUE SHIELD | OTHER | 00166 | 01 | ID | BLUE CROSS | OTHER | 1254303 | 01 | CIGNA GOVERNMENT SERVICES | OTHER |