Provider Demographics
NPI:1760610935
Name:POCATELLO HOSPITAL LLC
Entity Type:Organization
Organization Name:POCATELLO HOSPITAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVP, GENERAL COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:PETROVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-296-3594
Mailing Address - Street 1:651 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4071
Mailing Address - Country:US
Mailing Address - Phone:208-239-2110
Mailing Address - Fax:208-239-2145
Practice Address - Street 1:651 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4071
Practice Address - Country:US
Practice Address - Phone:208-239-2110
Practice Address - Fax:208-239-2145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-26
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 367500000X
ID12282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No282N00000XHospitalsGeneral Acute Care HospitalGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty