Healthcare Provider Details

I. General information

NPI: 1922205608
Provider Name (Legal Business Name): BMH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 02/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 POPLAR ST
BLACKFOOT ID
83221-1758
US

IV. Provider business mailing address

98 POPLAR ST
BLACKFOOT ID
83221-1758
US

V. Phone/Fax

Practice location:
  • Phone: 208-785-5801
  • Fax:
Mailing address:
  • Phone: 208-785-5801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LISA RUDOLPH
Title or Position: PSO SUPPORT SPECIALIST
Credential:
Phone: 208-782-3992