Provider Demographics
NPI:1386041119
Name:GRITMAN MEDICAL CENTER INC
Entity Type:Organization
Organization Name:GRITMAN MEDICAL CENTER INC
Other - Org Name:GRITMAN SWING BED PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-883-2220
Mailing Address - Street 1:700 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3056
Mailing Address - Country:US
Mailing Address - Phone:208-882-4511
Mailing Address - Fax:208-883-6580
Practice Address - Street 1:700 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3056
Practice Address - Country:US
Practice Address - Phone:208-882-4511
Practice Address - Fax:208-883-6580
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRITMAN MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-21
Last Update Date:2016-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID39314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1386041119Medicaid
ID1386041119Medicaid