Provider Demographics
NPI:1700659935
Name:POCATELLO HOSPITAL, LLC
Entity Type:Organization
Organization Name:POCATELLO HOSPITAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVP, GENERAL COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:PETROVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-296-3594
Mailing Address - Street 1:340 SEVEN SPRINGS WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5697
Mailing Address - Country:US
Mailing Address - Phone:615-296-3000
Mailing Address - Fax:
Practice Address - Street 1:777 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5175
Practice Address - Country:US
Practice Address - Phone:208-239-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:POCATELLO HEALTH SYSTEM, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-10-31
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site