ST. JOSEPH REGIONAL MEDICAL CENTER

Provider Demographics

• NPI: 1790816262
• Name: ST. JOSEPH REGIONAL MEDICAL CENTER
• Entity Type: Organization
• Organization Name: ST. JOSEPH REGIONAL MEDICAL CENTER
• Other - Org Name: ST. JOSEPH REGIONAL MEDICAL CENTER PHYSICIANS
• Other - Org Type: Other Name
• Authorized Official - Title/Position: DIRECTOR OF BUSINESS SERVICES
• Authorized Official - First Name: SUSAN
• Authorized Official - Last Name: COLBURN
• Authorized Official - Phone: 208-799-5200
• Mailing Address - Street 1: 415 6TH ST
• Mailing Address - City: LEWISTON
• Mailing Address - State: ID
• Mailing Address - Zip Code: 83501-2431
• Mailing Address - Country: US
• Mailing Address - Phone: 208-743-2511
• Mailing Address - Fax: 208-799-5554
• Practice Address - Street 1: 415 6TH ST
• Practice Address - City: LEWISTON
• Practice Address - State: ID
• Practice Address - Zip Code: 83501-2431
• Practice Address - Country: US
• Practice Address - Phone: 208-743-2511
• Practice Address - Fax: 208-799-5554
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2007-03-08
• Last Update Date: 2007-11-05

Provider Licenses

State	License ID	Taxonomies
ID		103T00000X, 207P00000X, 207RH0003X, 2084P0800X, 363A00000X, 363L00000X, 364S00000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	207P00000X	Allopathic & Osteopathic Physicians	Emergency Medicine		Group - Multi-Specialty
No	103T00000X	Behavioral Health & Social Service Providers	Psychologist		Group - Multi-Specialty
No	207RH0003X	Allopathic & Osteopathic Physicians	Internal Medicine	Hematology & Oncology	Group - Multi-Specialty
No	2084P0800X	Allopathic & Osteopathic Physicians	Psychiatry & Neurology	Psychiatry	Group - Multi-Specialty
No	363A00000X	Physician Assistants & Advanced Practice Nursing Providers	Physician Assistant		Group - Multi-Specialty
No	363L00000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner		Group - Multi-Specialty
No	364S00000X	Physician Assistants & Advanced Practice Nursing Providers	Clinical Nurse Specialist		Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
ID	000010005407	Other	REGENCE OF IDAHO
ID	000010005405	Other	REGENCE OF IDAHO
ID	8K552	Other	BLUE CROSS OF IDAHO
ID	000010005404	Other	REGENCE OF IDAHO
WA	7045891	Medicaid
WA	7046543	Medicaid
ID	8C576	Other	BLUE CROSS OF IDAHO
WA	7046279	Medicaid
ID	000010005405	Other	REGENCE OF IDAHO
ID	000010005404	Other	REGENCE OF IDAHO
ID	1252800	Medicare ID - Type Unspecified	CIGNA MEDICARE
WA	7046543	Medicaid