Provider Demographics
NPI:1073787784
Name:MINIDOKA MEMORIAL HOSPITAL CRNA GROUP
Entity Type:Organization
Organization Name:MINIDOKA MEMORIAL HOSPITAL CRNA GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-436-0481
Mailing Address - Street 1:1224 8TH ST
Mailing Address - Street 2:
Mailing Address - City:RUPERT
Mailing Address - State:ID
Mailing Address - Zip Code:83350-1527
Mailing Address - Country:US
Mailing Address - Phone:208-436-0481
Mailing Address - Fax:208-434-8675
Practice Address - Street 1:1224 8TH ST
Practice Address - Street 2:
Practice Address - City:RUPERT
Practice Address - State:ID
Practice Address - Zip Code:83350-1527
Practice Address - Country:US
Practice Address - Phone:208-436-0481
Practice Address - Fax:208-434-8675
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MINIDOKA MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-15
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
002336000OtherBLUE SHIELD
IDM8068633Medicaid
00166OtherBLUE CROSS OF IDAHO
002336000OtherBLUE SHIELD