Healthcare Provider Details

I. General information

NPI: 1487272399
Provider Name (Legal Business Name): SHOSHONE MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2020
Last Update Date: 04/27/2021
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 JACOBS GULCH RD
KELLOGG ID
83837-2023
US

IV. Provider business mailing address

25 JACOBS GULCH RD
KELLOGG ID
83837-2023
US

V. Phone/Fax

Practice location:
  • Phone: 208-784-4612
  • Fax: 208-786-1019
Mailing address:
  • Phone: 208-784-1228
  • Fax: 208-786-1019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DONJA C ERDMAN
Title or Position: CFO
Credential:
Phone: 208-784-1221