Provider Demographics
NPI:1245433739
Name:ST. MARY'S HOSPITAL
Entity type:Organization
Organization Name:ST. MARY'S HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR BUSINESS SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:A
Authorized Official - Last Name:UPTMOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-962-2301
Mailing Address - Street 1:701 LEWISTON ST
Mailing Address - Street 2:P O BOX 137
Mailing Address - City:COTTONWOOD
Mailing Address - State:ID
Mailing Address - Zip Code:83522
Mailing Address - Country:US
Mailing Address - Phone:208-962-3251
Mailing Address - Fax:208-962-3722
Practice Address - Street 1:701 LEWISTON ST
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:ID
Practice Address - Zip Code:83522
Practice Address - Country:US
Practice Address - Phone:208-962-3251
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID33367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010158532OtherBLUE SHIELD GROUP PROV #
ID002286200Medicaid