Provider Demographics
NPI:1922037530
Name:ST BENEDICTS FAMILY MEDICAL CENTER
Entity type:Organization
Organization Name:ST BENEDICTS FAMILY MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:STEVENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-324-1122
Mailing Address - Street 1:115 5TH AVE W
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338-1824
Mailing Address - Country:US
Mailing Address - Phone:208-324-8831
Mailing Address - Fax:208-324-6678
Practice Address - Street 1:115 5TH AVE W
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-1824
Practice Address - Country:US
Practice Address - Phone:208-324-8831
Practice Address - Fax:208-324-6678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807893400Medicaid
ID002287100Medicaid
ID8A489OtherBLUE CROSS OF IDAHO
ID000010006293OtherREGENCE BLUE SHIELD OF ID
ID807893400Medicaid
ID807893400Medicaid