Provider Demographics
NPI:1083796569
Name:SALMON RIVER CLINIC HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:SALMON RIVER CLINIC HOSPITAL DISTRICT
Other - Org Name:SALMON RIVER CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PA/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:MERCANTINI
Authorized Official - Last Name:KLINGLER
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:208-774-3565
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:STANLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83278-0129
Mailing Address - Country:US
Mailing Address - Phone:208-774-3565
Mailing Address - Fax:
Practice Address - Street 1:1 NIECE AVENUE
Practice Address - Street 2:
Practice Address - City:STANLEY
Practice Address - State:ID
Practice Address - Zip Code:83278-0129
Practice Address - Country:US
Practice Address - Phone:208-774-3565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-4162207Q00000X
IDPA-492363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806387200Medicaid
ID13-3808Medicare ID - Type Unspecified