Provider Demographics
NPI:1043215437
Name:SHOSHONE MEDICAL CENTER
Entity Type:Organization
Organization Name:SHOSHONE MEDICAL CENTER
Other - Org Name:WEST SHOSHONE HOSPITAL DISTRICT
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MISS
Authorized Official - First Name:DONJA
Authorized Official - Middle Name:
Authorized Official - Last Name:ERDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-784-1221
Mailing Address - Street 1:25 JACOBS GULCH RD
Mailing Address - Street 2:
Mailing Address - City:KELLOGG
Mailing Address - State:ID
Mailing Address - Zip Code:83837-2023
Mailing Address - Country:US
Mailing Address - Phone:208-784-7017
Mailing Address - Fax:208-786-1019
Practice Address - Street 1:25 JACOBS GULCH RD
Practice Address - Street 2:
Practice Address - City:KELLOGG
Practice Address - State:ID
Practice Address - Zip Code:83837-2023
Practice Address - Country:US
Practice Address - Phone:208-784-7017
Practice Address - Fax:208-786-1019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID44282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID86405OtherBLUE CROSS OF IDAHO
3504605OtherMONTANA MEDICAID
ID002862700Medicaid
3016300OtherWASHINGTON MEDICAID
0082553OtherWASHINGTON L & I
411320OtherMONTANA MEDICAID
ID000010000167OtherREGENCE
ID002861700Medicaid
ID00513OtherBLUE CROSS OF IDAHO
10004OtherWASHINGTON L & I
7043250OtherWASHINGTON MEDICAID
ID002861800Medicaid
ID002861700Medicaid
ID13Z314Medicare Oscar/Certification
0082553OtherWASHINGTON L & I