Healthcare Provider Details

I. General information

NPI: 1376871749
Provider Name (Legal Business Name): BEAR LAKE COUNTY MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2009
Last Update Date: 01/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 S 5TH ST
MONTPELIER ID
83254-1557
US

IV. Provider business mailing address

164 S 5TH ST
MONTPELIER ID
83254-1557
US

V. Phone/Fax

Practice location:
  • Phone: 208-847-4354
  • Fax: 208-847-2201
Mailing address:
  • Phone: 208-847-4354
  • Fax: 208-847-2201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ROD JACOBSON
Title or Position: CEO
Credential:
Phone: 208-847-1630