Provider Demographics
NPI:1114112216
Name:SOUTHWEST IDAHO ADVANCED CARE HOSPITAL INC -A DELAWARE CORP-
Entity Type:Organization
Organization Name:SOUTHWEST IDAHO ADVANCED CARE HOSPITAL INC -A DELAWARE CORP-
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CLAUDE
Authorized Official - Middle Name:DARBY
Authorized Official - Last Name:BROCKETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-856-5300
Mailing Address - Street 1:6651 W FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709
Mailing Address - Country:US
Mailing Address - Phone:505-856-5300
Mailing Address - Fax:
Practice Address - Street 1:6651 W FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709
Practice Address - Country:US
Practice Address - Phone:505-856-5300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282E00000XHospitalsLong Term Care HospitalGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Single Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID132003Medicare Oscar/Certification