Provider Demographics
NPI:1538634522
Name:GRITMAN MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:GRITMAN MEDICAL CENTER, INC.
Other - Org Name:MOSCOW FAMILY MEDICINE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:LYNAS
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:83843-3046
Mailing Address - Country:US
Mailing Address - Phone:208-882-4511
Mailing Address - Fax:208-883-6580
Practice Address - Street 1:623 S MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3042
Practice Address - Country:US
Practice Address - Phone:208-882-2011
Practice Address - Fax:208-883-1853
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRITMAN MEDICAL CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-10-05
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID39OtherSTATE OF IDAHO LICENSE