Healthcare Provider Details

I. General information

NPI: 1174577100
Provider Name (Legal Business Name): ST. MARY'S HOSPITAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 01/27/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 LEWISTON ST
COTTONWOOD ID
83522-9750
US

IV. Provider business mailing address

2003 KOOTENAI HEALTH WAY
COEUR D ALENE ID
83814-6051
US

V. Phone/Fax

Practice location:
  • Phone: 208-962-3267
  • Fax: 208-962-2313
Mailing address:
  • Phone: 208-625-5085
  • Fax: 208-625-5731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateID

VIII. Authorized Official

Name: LENNE BONNER
Title or Position: CEO
Credential:
Phone: 208-476-4555