Provider Demographics
NPI:1336200096
Name:MCCALL MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:MCCALL MEMORIAL HOSPITAL
Other - Org Name:INTEGRATIVE MEDICINE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KELLIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-634-2221
Mailing Address - Street 1:1000 STATE ST
Mailing Address - Street 2:
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638-3704
Mailing Address - Country:US
Mailing Address - Phone:208-634-2221
Mailing Address - Fax:208-634-7112
Practice Address - Street 1:203 HEWITT ST
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638-3704
Practice Address - Country:US
Practice Address - Phone:208-634-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID11261QC0050X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC0050XAmbulatory Health Care FacilitiesClinic/CenterCritical Access Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8M924OtherBLUE CROSS CLINIC #
ID8M924OtherBLUE CROSS CLINIC #