Organization
ST BENEDICTS FAMILY MEDICAL CENTER
Active
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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