Provider Demographics
NPI:1437191418
Name:PORTNEUF MEDICAL CENTER
Entity type:Organization
Organization Name:PORTNEUF MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP FINANCE & CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOHNATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-239-1020
Mailing Address - Street 1:651 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4071
Mailing Address - Country:US
Mailing Address - Phone:208-239-1000
Mailing Address - Fax:208-239-1970
Practice Address - Street 1:651 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4071
Practice Address - Country:US
Practice Address - Phone:208-239-1000
Practice Address - Fax:208-239-1970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDH12183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty