Provider Demographics
NPI:1821091083
Name:WALTER KNOX MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:WALTER KNOX MEMORIAL HOSPITAL
Other - Org Name:VALOR HEALTH - EMMETT MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:TURPEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-999-3870
Mailing Address - Street 1:1102 E LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-2713
Mailing Address - Country:US
Mailing Address - Phone:208-365-6004
Mailing Address - Fax:208-365-3589
Practice Address - Street 1:1102 E LOCUST ST
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-2713
Practice Address - Country:US
Practice Address - Phone:208-365-6004
Practice Address - Fax:208-365-3589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2019-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID13-8525261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID13-8525OtherRURAL HEALTH CLINIC PTAN
ID8E001OtherBLUE CROSS OF IDAHO GROUP
ID805187500Medicaid
138525OtherUNSPECIFIED
ID002563400Medicaid
ID002563800Medicaid
ID138525OtherMEDICARE PTAN
ID806367900Medicaid
ID807437800Medicaid
ID000010006204OtherREGENCE BLUE SH OF ID GRP
ID000269700Medicaid
ID002563800Medicaid
ID002563400Medicaid
ID8E001OtherBLUE CROSS OF IDAHO GROUP
138525OtherUNSPECIFIED
ID138525OtherMEDICARE PTAN
ID000269700Medicaid
ID805187500Medicaid