Provider Demographics
NPI:1790846392
Name:MCCALL MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:MCCALL MEMORIAL HOSPITAL
Other - Org Name:MID LEVEL PRACTITIONER GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KELLIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-634-2221
Mailing Address - Street 1:1000 STATE ST
Mailing Address - Street 2:
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638-3704
Mailing Address - Country:US
Mailing Address - Phone:208-634-2221
Mailing Address - Fax:208-634-7112
Practice Address - Street 1:1000 STATE ST
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638-3704
Practice Address - Country:US
Practice Address - Phone:208-634-2221
Practice Address - Fax:208-634-7112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID11363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty