Provider Demographics
NPI:1295748457
Name:CEDAR MOUNTAIN MEDICAL INC.
Entity type:Organization
Organization Name:CEDAR MOUNTAIN MEDICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-777-9199
Mailing Address - Street 1:PO BOX 3250
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83877-3250
Mailing Address - Country:US
Mailing Address - Phone:208-777-9199
Mailing Address - Fax:208-777-8580
Practice Address - Street 1:503 E SELTICE WAY STE 8
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-6499
Practice Address - Country:US
Practice Address - Phone:208-777-9199
Practice Address - Fax:208-777-8580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806797600Medicaid
WA0144814OtherWA DEPT OF LABOR
ID000010014605OtherBLUE SHIELD OF ID
ID001274700Medicaid
WA9048430Medicaid
ID03566OtherBLUE CROSS OF IDAHO, GA,
WA0144814OtherWA DEPT OF LABOR