Healthcare Provider Details

I. General information

NPI: 1922037530
Provider Name (Legal Business Name): ST BENEDICTS FAMILY MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 05/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 5TH AVE W
JEROME ID
83338-1824
US

IV. Provider business mailing address

115 5TH AVE W
JEROME ID
83338-1824
US

V. Phone/Fax

Practice location:
  • Phone: 208-324-8831
  • Fax: 208-324-6678
Mailing address:
  • Phone: 208-324-8831
  • Fax: 208-324-6678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateID

VIII. Authorized Official

Name: MR. WARREN ALAN STEVENSON
Title or Position: CEO
Credential:
Phone: 208-324-1122