Provider Demographics
NPI:1710203237
Name:ST. MARY'S HOSPITAL
Entity Type:Organization
Organization Name:ST. MARY'S HOSPITAL
Other - Org Name:ST. MARY'S GRANGEVILLE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:GATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-476-8083
Mailing Address - Street 1:617 W NORTH ST
Mailing Address - Street 2:
Mailing Address - City:GRANGEVILLE
Mailing Address - State:ID
Mailing Address - Zip Code:83530-1239
Mailing Address - Country:US
Mailing Address - Phone:208-962-3267
Mailing Address - Fax:208-962-2313
Practice Address - Street 1:617 W NORTH ST
Practice Address - Street 2:
Practice Address - City:GRANGEVILLE
Practice Address - State:ID
Practice Address - Zip Code:83530-1239
Practice Address - Country:US
Practice Address - Phone:208-962-3267
Practice Address - Fax:208-962-2313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-08
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID207Q00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty