Provider Demographics
NPI:1073559993
Name:ST BENEDICTS FAMILY MEDICAL CENTER
Entity Type:Organization
Organization Name:ST BENEDICTS FAMILY MEDICAL CENTER
Other - Org Name:ST BENEDICTS FAMILY CLINIC-WENDELL
Other - Org Type:Other Name
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:CURTIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MAIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-324-1122
Mailing Address - Street 1:280 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WENDELL
Mailing Address - State:ID
Mailing Address - Zip Code:83355-5201
Mailing Address - Country:US
Mailing Address - Phone:208-563-6663
Mailing Address - Fax:208-536-5182
Practice Address - Street 1:280 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WENDELL
Practice Address - State:ID
Practice Address - Zip Code:83355-5201
Practice Address - Country:US
Practice Address - Phone:208-563-6663
Practice Address - Fax:208-536-5182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010142896OtherREGENCE BLUE SHIELD OF ID
ID8G882OtherBLUE CROSS OF IDAHO
ID000010142896OtherREGENCE BLUE SHIELD OF ID
ID133661Medicare ID - Type UnspecifiedRHC
ID8G882OtherBLUE CROSS OF IDAHO