Organization
STATE OF IDAHO DEPARTMENT OF HEALTH AND WELFARE
Active
Organization
STATE OF IDAHO DEPARTMENT OF HEALTH AND WELFARE
Active
Parent organization
STATE HOSPITAL SOUTH
Other names
State Hospital South Medical Clinic
Organization subpart
Yes
Provider details
NPI number
Legal business name
STATE HOSPITAL SOUTH
Authorized official
LYNN D SHIELDS (PATIENT ACCOUNTS SPECIALIST)
(208) 785-8462
Entity
Organization
Contact information
Practice address
700 E. ALICE, BOX 400, BLACKFOOT, ID 83221-0400
(208) 785-1200
(208) 785-8518
Mailing address
700 E. ALICE, PO BOX 400, BLACKFOOT, ID 83221-0400
(208) 785-1200
(208) 785-8518
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
17
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
002823200
—
ID
Enumeration date
12/28/2006
Last updated
07/15/2016
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