Provider Demographics
NPI:1174741441
Name:BEAR LAKE COUNTY MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:BEAR LAKE COUNTY MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTRACT MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-847-4327
Mailing Address - Street 1:166 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:ID
Mailing Address - Zip Code:83254-1557
Mailing Address - Country:US
Mailing Address - Phone:208-847-1110
Mailing Address - Fax:208-847-0228
Practice Address - Street 1:166 S 5TH ST
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:ID
Practice Address - Zip Code:83254-1557
Practice Address - Country:US
Practice Address - Phone:208-847-1110
Practice Address - Fax:208-847-0228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7743207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806833500Medicaid
ID806833500Medicaid
ID=========OtherEIN
ID138505Medicare ID - Type UnspecifiedRURAL HEALTH CLINIC
ID806833500Medicaid