Provider Demographics
NPI:1851371959
Name:MOUNTAIN RIVER BIRTHING AND SURGERY CENTER LLC
Entity Type:Organization
Organization Name:MOUNTAIN RIVER BIRTHING AND SURGERY CENTER LLC
Other - Org Name:IDAHO DOCTORS HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-785-3801
Mailing Address - Street 1:350 N MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1625
Mailing Address - Country:US
Mailing Address - Phone:208-782-0300
Mailing Address - Fax:
Practice Address - Street 1:350 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1625
Practice Address - Country:US
Practice Address - Phone:208-782-0300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-17
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010147223OtherBLUE SHIELD PROVIDER #
ID04630OtherBLUE CROSS PROVIDER #
ID806958900Medicaid