MEDICARE: ST. MARY'S HOSPITAL

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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1790919991
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. MARY'S HOSPITAL

Provider Business Mailing Address
First Line	:	617 W NORTH ST
Second Line	:
City	:	GRANGEVILLE
State	:	ID
Zip	:	83530-1239
Country	:	US
Telephone Number	:	208-983-2241
Fax Number	:	208-983-2766

Provider Business Practice Location Address
First Line	:	617 W NORTH ST
Second Line	:
City	:	GRANGEVILLE
State	:	ID
Zip	:	83530-1239
Country	:	US
Telephone Number	:	208-983-2241
Fax Number	:	208-983-2766

Authorized Official
Title or Position	:	CHIEF BUSINESS SERVICES OFFICER
Name	:	MS. THERESA A UPTMOR
Credential	:
Telephone Number	:	208-962-2301

Provider Enumeration Date	:	05/04/2009
Last Update Date	:	04/07/2015

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Directions to “ST. MARY'S HOSPITAL ” Practice Location

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