Provider Demographics
NPI:1942567847
Name:GRITMAN MEDICAL CENTER INC
Entity Type:Organization
Organization Name:GRITMAN MEDICAL CENTER INC
Other - Org Name:TROY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-883-2220
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:208-883-6571
Practice Address - Street 1:412 S MAIN ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:ID
Practice Address - Zip Code:83871-0415
Practice Address - Country:US
Practice Address - Phone:208-835-5550
Practice Address - Fax:208-883-6580
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRITMAN MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-16
Last Update Date:2016-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty