Provider Demographics
NPI:1235626474
Name:GRITMAN MEDICAL CENTER INC
Entity Type:Organization
Organization Name:GRITMAN MEDICAL CENTER INC
Other - Org Name:GRITMAN PSYCHIATRIC SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PFS SUPER VISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:THORSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-885-4511
Mailing Address - Street 1:PO BOX 8007
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-0507
Mailing Address - Country:US
Mailing Address - Phone:208-882-4511
Mailing Address - Fax:208-883-6580
Practice Address - Street 1:803 S MAIN ST STE 210
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2695
Practice Address - Country:US
Practice Address - Phone:208-883-6774
Practice Address - Fax:208-883-1398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-13
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID392084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty