Provider Demographics
NPI:1265442388
Name:MCCALL MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:MCCALL MEMORIAL HOSPITAL
Other - Org Name:MCCALL THERAPY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:GROENIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-634-2221
Mailing Address - Street 1:1000 STATE ST
Mailing Address - Street 2:
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638-3704
Mailing Address - Country:US
Mailing Address - Phone:208-634-2221
Mailing Address - Fax:208-634-7112
Practice Address - Street 1:1010 STATE STREET
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638-3704
Practice Address - Country:US
Practice Address - Phone:208-634-2221
Practice Address - Fax:208-634-7112
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCCALL MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-09
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID11261QC0050X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC0050XAmbulatory Health Care FacilitiesClinic/CenterCritical Access Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807424900Medicaid
ID000010147637OtherREGENCE CLINIC GRP #
ID8J612OtherBLUE CROSS CLINIC GRP #
ID806937700Medicaid
ID1253003Medicare PIN
ID807424900Medicaid