Provider Demographics
NPI:1598831653
Name:STATE HOSPITAL NORTH
Entity Type:Organization
Organization Name:STATE HOSPITAL NORTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BOURASSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-476-4511
Mailing Address - Street 1:300 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:OROFINO
Mailing Address - State:ID
Mailing Address - Zip Code:83544-9034
Mailing Address - Country:US
Mailing Address - Phone:208-476-4511
Mailing Address - Fax:208-476-7898
Practice Address - Street 1:300 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:OROFINO
Practice Address - State:ID
Practice Address - Zip Code:83544-9034
Practice Address - Country:US
Practice Address - Phone:208-476-4511
Practice Address - Fax:208-476-7898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID24283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1400501OtherCLIA
ID00919OtherBLUE CROSS OF IDAHO