Provider Demographics
NPI:1669493417
Name:ST. MARY'S HOSPITAL
Entity Type:Organization
Organization Name:ST. MARY'S HOSPITAL
Other - Org Name:ST. MARY'S HOSPITAL SWING BED
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT TO CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:A
Authorized Official - Last Name:UPTMOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-962-2301
Mailing Address - Street 1:PO BOX 137
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:ID
Mailing Address - Zip Code:83522-0137
Mailing Address - Country:US
Mailing Address - Phone:208-962-2301
Mailing Address - Fax:
Practice Address - Street 1:701 LEWISTON ST
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:ID
Practice Address - Zip Code:83522
Practice Address - Country:US
Practice Address - Phone:208-962-3251
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARY'S HOSPITAL INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-21
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID33275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002286100Medicaid
ID13Z321Medicare Oscar/Certification