Provider Demographics
NPI:1518377019
Name:NORTH CANYON MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:NORTH CANYON MEDICAL CENTER, INC.
Other - Org Name:NORTH CANYON FAMILY MEDICINE
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:POWERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-934-8765
Mailing Address - Street 1:267 N CANYON DRIVE
Mailing Address - Street 2:MEDICAL PLAZA
Mailing Address - City:GOODING
Mailing Address - State:ID
Mailing Address - Zip Code:83330
Mailing Address - Country:US
Mailing Address - Phone:208-934-4446
Mailing Address - Fax:208-934-4442
Practice Address - Street 1:267 N. CANYON DRIVE
Practice Address - Street 2:
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330
Practice Address - Country:US
Practice Address - Phone:208-934-4446
Practice Address - Fax:208-934-4442
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTH CANYON MEDICAL CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-06
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1609046671OtherNORTH CANYON MEDICAL CENTER
ID1518377019OtherRHC
ID138520OtherUNSPECIFIED
ID138520Medicare Oscar/Certification
ID1518377019OtherRHC