Provider Demographics
NPI:1336125533
Name:BEAR LAKE COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:BEAR LAKE COUNTY MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-847-4402
Mailing Address - Street 1:164 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:ID
Mailing Address - Zip Code:83254-1557
Mailing Address - Country:US
Mailing Address - Phone:208-847-1630
Mailing Address - Fax:208-847-2201
Practice Address - Street 1:164 S 5TH ST
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:ID
Practice Address - Zip Code:83254-1557
Practice Address - Country:US
Practice Address - Phone:208-847-1630
Practice Address - Fax:208-847-2201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID35282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID131316Medicare ID - Type Unspecified