Provider Demographics
NPI:1639373772
Name:MEMORIAL HOSPITAL - RADIOLOGY
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL - RADIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WADE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-549-4450
Mailing Address - Street 1:645 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:WEISER
Mailing Address - State:ID
Mailing Address - Zip Code:83672-2202
Mailing Address - Country:US
Mailing Address - Phone:208-549-0370
Mailing Address - Fax:208-414-4267
Practice Address - Street 1:645 E 5TH ST
Practice Address - Street 2:
Practice Address - City:WEISER
Practice Address - State:ID
Practice Address - Zip Code:83672-2202
Practice Address - Country:US
Practice Address - Phone:208-549-0370
Practice Address - Fax:208-414-4267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID32282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8K396OtherBLUE CROSS GROUP
ID002851300Medicaid
OR121244Medicaid
WA3032901Medicaid
ID000010027650OtherBLUE SHIELD RADY
ID000010027650OtherBLUE SHIELD RADY