Provider Demographics
NPI:1366542391
Name:BLACKFOOT MEDICAL CLINIC, INC
Entity type:Organization
Organization Name:BLACKFOOT MEDICAL CLINIC, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:
Authorized Official - Last Name:TIBBITTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-785-2600
Mailing Address - Street 1:210 S EMERSON ST
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 S EMERSON ST
Practice Address - Street 2:
Practice Address - City:SHELLEY
Practice Address - State:ID
Practice Address - Zip Code:83274
Practice Address - Country:US
Practice Address - Phone:208-357-7404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID133839Medicare Oscar/Certification
ID1374715Medicare PIN
ID0363970001Medicare NSC