Provider Demographics
NPI:1104004928
Name:IDAHO DEPT OF HEALTH & WELFARE AMHCALPGREG3
Entity Type:Organization
Organization Name:IDAHO DEPT OF HEALTH & WELFARE AMHCALPGREG3
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FIELD OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:L
Authorized Official - Last Name:HURT
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:208-455-7057
Mailing Address - Street 1:3402 FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-6932
Mailing Address - Country:US
Mailing Address - Phone:208-459-0092
Mailing Address - Fax:208-454-7714
Practice Address - Street 1:3402 FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-6932
Practice Address - Country:US
Practice Address - Phone:208-459-0092
Practice Address - Fax:208-454-7714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-04
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HW298OtherBLUE CROSS OF IDAHO
ID8076191Medicaid
ID000010027633OtherBLUESHIELD