Provider Demographics
NPI:1245670793
Name:ASHTON MEMORIAL, INC.
Entity type:Organization
Organization Name:ASHTON MEMORIAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HR DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-652-7461
Mailing Address - Street 1:1301 E 17TH ST STE 4
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6273
Mailing Address - Country:US
Mailing Address - Phone:208-523-0787
Mailing Address - Fax:208-523-3175
Practice Address - Street 1:1301 E 17TH ST STE 4
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6273
Practice Address - Country:US
Practice Address - Phone:208-523-0787
Practice Address - Fax:208-523-3175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1003907163Medicaid
ID1370093Medicare UPIN