Provider Demographics
NPI:1265564967
Name:MCCALL MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:MCCALL MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
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 1:454 WEST ROSEBERRY RD, SUITE 103
Practice Address - Street 2:
Practice Address - City:DONNELLY
Practice Address - State:ID
Practice Address - Zip Code:83615
Practice Address - Country:US
Practice Address - Phone:208-325-4455
Practice Address - Fax:208-325-4466
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCCALL MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-09
Last Update Date:2008-02-15
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
ID000010159605OtherREGENCE CLINIC NUMBER
ID8M977OtherBLUE CROSS OF ID CLINIC
ID000010159605OtherREGENCE CLINIC NUMBER
ID131312Medicare Oscar/Certification