Provider Demographics
NPI:1114010782
Name:REXBURG MEDICAL CENTER
Entity Type:Organization
Organization Name:REXBURG MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:ZOLLINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-356-5401
Mailing Address - Street 1:393 E 2ND N
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440
Mailing Address - Country:US
Mailing Address - Phone:208-356-5401
Mailing Address - Fax:208-356-3111
Practice Address - Street 1:393 E 2ND N
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440
Practice Address - Country:US
Practice Address - Phone:208-356-5401
Practice Address - Fax:208-356-3111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4211207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID29920OtherBLUE SHIELD OF IDAHO
ID8981-3OtherBLUE CROSS
ID8981-3OtherBLUE CROSS