Provider Demographics
NPI:1790182590
Name:GRITMAN MEDICAL CENTER INC.
Entity Type:Organization
Organization Name:GRITMAN MEDICAL CENTER INC.
Other - Org Name:GRITMAN INTERNAL MEDICINE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:PRESTON
Authorized Official - Middle Name:J
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-883-2221
Mailing Address - Street 1:700 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3056
Mailing Address - Country:US
Mailing Address - Phone:208-882-4511
Mailing Address - Fax:208-883-6580
Practice Address - Street 1:804 S WASHINGTON ST STE A
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3182
Practice Address - Country:US
Practice Address - Phone:208-883-1152
Practice Address - Fax:208-882-1486
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRITMAN MEDICAL CENTER INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-24
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID39261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1253203Medicare PIN