Provider Demographics
NPI:1700076510
Name:MOUNTAIN HEALTH MID LEVEL
Entity Type:Organization
Organization Name:MOUNTAIN HEALTH MID LEVEL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-783-1267
Mailing Address - Street 1:740 MCKINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:KELLOGG
Mailing Address - State:ID
Mailing Address - Zip Code:83837-2693
Mailing Address - Country:US
Mailing Address - Phone:208-783-1267
Mailing Address - Fax:208-786-4471
Practice Address - Street 1:740 MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:KELLOGG
Practice Address - State:ID
Practice Address - Zip Code:83837-2693
Practice Address - Country:US
Practice Address - Phone:208-783-1267
Practice Address - Fax:208-786-4471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA28363AM0700X
IDPA301363AM0700X
IDPA580363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002791000Medicaid
IDCC9834OtherRAILROAD MEDICARE
ID8A570OtherBLUE CROSS
ID000010006537OtherREGENCE
ID002791000Medicaid
ID1374793Medicare PIN