Organization
ST BENEDICTS FAMILY MEDICAL CENTER
Active
Other names
FIFTH AVENUE CLINIC
Organization subpart
No
Provider details
NPI number
Authorized official
MR. WARREN ALAN STEVENSON (CEO)
(208) 324-1122
Entity
Organization
Contact information
Practice address
115 5TH AVE W, JEROME, ID 83338-1824
(208) 324-8831
(208) 324-6678
Mailing address
115 5TH AVE W, JEROME, ID 83338-1824
(208) 324-8831
(208) 324-6678
Taxonomy
Speciality
Code
Description
License number
State
261QM1300X
Multi-Specialty Clinic/Center
Primary
—
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010006293
REGENCE BLUE SHIELD OF ID
ID
05
—
002287100
—
ID
05
—
807893400
—
ID
01
—
8A489
BLUE CROSS OF IDAHO
ID
Enumeration date
07/03/2006
Last updated
05/08/2008
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