Organization
ST. MARY'S HOSPITAL
Active
Other names
Anesthesia Group
Organization subpart
No
Provider details
NPI number
Authorized official
THERESA A UPTMOR (DIRECTOR BUSINESS SERVICES)
(208) 962-2301
Entity
Organization
Contact information
Practice address
701 LEWISTON ST, COTTONWOOD, ID 83522
(208) 962-3251
Mailing address
701 LEWISTON ST, P O BOX 137, COTTONWOOD, ID 83522
(208) 962-3251
(208) 962-3722
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
33
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010158532
BLUE SHIELD GROUP PROV #
ID
05
—
002286200
—
ID
Enumeration date
06/11/2007
Last updated
05/11/2009
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