Provider Demographics
NPI:1417122821
Name:ELMORE MEDICAL CENTER SPECIALTY PHYSICIAN GROUP
Entity Type:Organization
Organization Name:ELMORE MEDICAL CENTER SPECIALTY PHYSICIAN GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:JANOUSEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-587-8401
Mailing Address - Street 1:PO BOX 1270
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-1270
Mailing Address - Country:US
Mailing Address - Phone:208-587-8401
Mailing Address - Fax:208-587-8406
Practice Address - Street 1:890 N 6TH E
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-2206
Practice Address - Country:US
Practice Address - Phone:208-587-8401
Practice Address - Fax:208-587-8406
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELMORE MEDICAL CENTER HOSPITAL DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-25
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010149755OtherBLUE SHIELD PROF NUMBER
ID000014148578OtherBLUE SHIELD
ID002860700Medicaid
ID8K594OtherBLUE CROSS
ID002860700Medicaid
ID000010149755OtherBLUE SHIELD PROF NUMBER