Organization
MOUNTAIN HEALTH MID LEVEL
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. LYNN HAUGHN (OFFICE MANAGER)
(208) 783-1267
Entity
Organization
Contact information
Practice address
740 MCKINLEY AVE, KELLOGG, ID 83837-2693
(208) 783-1267
(208) 786-4471
Mailing address
740 MCKINLEY AVE, KELLOGG, ID 83837-2693
(208) 783-1267
(208) 786-4471
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA28
ID
363AM0700X
Medical Physician Assistant
PA301
ID
363AM0700X
Medical Physician Assistant
PA580
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010006537
REGENCE
ID
05
—
002791000
—
ID
01
—
8A570
BLUE CROSS
ID
01
—
CC9834
RAILROAD MEDICARE
ID
Enumeration date
07/27/2007
Last updated
08/15/2008
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