Provider Demographics
NPI:1427198092
Name:ST. JOSEPH REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:ST. JOSEPH REGIONAL MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BUSINESS SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-799-5200
Mailing Address - Street 1:415 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2431
Mailing Address - Country:US
Mailing Address - Phone:208-743-2511
Mailing Address - Fax:208-799-5554
Practice Address - Street 1:415 6TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2431
Practice Address - Country:US
Practice Address - Phone:208-743-2511
Practice Address - Fax:208-799-5554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID332B00000X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6009633Medicaid
ID002271500Medicaid
ID8E365OtherBLUE CROSS OF ID DME
ID000010033840OtherREGENCE OF ID DME
ID0878300001Medicare NSC