MEDICARE: ASHTON MEMORIAL, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245670793
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ASHTON MEMORIAL, INC.

Provider Business Mailing Address
First Line	:	1301 E 17TH ST STE 4
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-6273
Country	:	US
Telephone Number	:	208-523-0787
Fax Number	:	208-523-3175

Provider Business Practice Location Address
First Line	:	1301 E 17TH ST STE 4
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-6273
Country	:	US
Telephone Number	:	208-523-0787
Fax Number	:	208-523-3175

Authorized Official
Title or Position	:	HR DIRECTOR
Name	:	SUZANNE BRADY
Credential	:
Telephone Number	:	205-652-7461

Provider Enumeration Date	:	06/28/2013
Last Update Date	:	06/28/2013

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Directions to “ASHTON MEMORIAL, INC. ” Practice Location

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