Provider Demographics
NPI:1164539912
Name:MOUNTAIN HEALTH SERVICES PC
Entity Type:Organization
Organization Name:MOUNTAIN HEALTH SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:R
Authorized Official - Last Name:HALLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-783-1267
Mailing Address - Street 1:740 MCKINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:KELLOGG
Mailing Address - State:ID
Mailing Address - Zip Code:83837-2693
Mailing Address - Country:US
Mailing Address - Phone:208-783-1267
Mailing Address - Fax:208-786-4471
Practice Address - Street 1:740 MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:KELLOGG
Practice Address - State:ID
Practice Address - Zip Code:83837-2693
Practice Address - Country:US
Practice Address - Phone:208-783-1267
Practice Address - Fax:208-786-4471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8355207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002790500Medicaid
ID000010006537OtherREGENCE
IDCC9834OtherRAILROAD MEDICARE
ID8A570OtherBLUE CROSS OF IDAHO
ID000010006537OtherREGENCE
ID1185830001Medicare NSC