Provider Demographics
NPI:1073802492
Name:SYRINGA GENERAL HOSPITAL DISTRICT CIF
Entity Type:Organization
Organization Name:SYRINGA GENERAL HOSPITAL DISTRICT CIF
Other - Org Name:SYRINGA PRIMARY CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-983-1700
Mailing Address - Street 1:722 W NORTH ST
Mailing Address - Street 2:
Mailing Address - City:GRANGEVILLE
Mailing Address - State:ID
Mailing Address - Zip Code:83530-1350
Mailing Address - Country:US
Mailing Address - Phone:208-983-8590
Mailing Address - Fax:208-983-8580
Practice Address - Street 1:607 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GRANGEVILLE
Practice Address - State:ID
Practice Address - Zip Code:83530-1345
Practice Address - Country:US
Practice Address - Phone:208-983-1700
Practice Address - Fax:208-983-2114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-06
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID18261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID138517Medicare Oscar/Certification