Healthcare Provider Details

I. General information

NPI: 1790343580
Provider Name (Legal Business Name): SNAKE RIVER HOSPITALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2019
Last Update Date: 06/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 CORONADO ST
IDAHO FALLS ID
83404-7407
US

IV. Provider business mailing address

2325 CORONADO ST
IDAHO FALLS ID
83404-7407
US

V. Phone/Fax

Practice location:
  • Phone: 208-557-2700
  • Fax:
Mailing address:
  • Phone: 208-557-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: NED HILLYARD
Title or Position: CHIEF COMPLIANCE OFFICER
Credential:
Phone: 208-709-4571