Provider Demographics
NPI:1043387426
Name:MINIDOKA MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:MINIDOKA MEMORIAL HOSPITAL
Other - Org Name:MINIDOKA MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:MURPHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-436-8141
Mailing Address - Street 1:1308 8TH ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:RUPERT
Mailing Address - State:ID
Mailing Address - Zip Code:83350-1530
Mailing Address - Country:US
Mailing Address - Phone:208-436-4322
Mailing Address - Fax:208-436-1312
Practice Address - Street 1:1308 8TH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:RUPERT
Practice Address - State:ID
Practice Address - Zip Code:83350-1530
Practice Address - Country:US
Practice Address - Phone:208-436-4322
Practice Address - Fax:208-436-1312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMMCRHC261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID00001002451OtherBLUE SHIELD
ID74146OtherBLUE CROSS
IDM8073867Medicaid
ID1254303Medicare PIN
ID00001002451OtherBLUE SHIELD