Provider Demographics
NPI:1235160441
Name:BLACKFOOT MEDICAL CLINIC, INC
Entity Type:Organization
Organization Name:BLACKFOOT MEDICAL CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-785-2600
Mailing Address - Street 1:1441 PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1667
Mailing Address - Country:US
Mailing Address - Phone:208-785-2600
Mailing Address - Fax:208-785-8185
Practice Address - Street 1:1441 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1667
Practice Address - Country:US
Practice Address - Phone:208-785-2600
Practice Address - Fax:208-785-8185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002333900Medicaid
ID002333900Medicaid
ID1374715Medicare PIN
ID1374716Medicare PIN
ID133831Medicare Oscar/Certification