Healthcare Provider Details

I. General information

NPI: 1336125533
Provider Name (Legal Business Name): BEAR LAKE COUNTY MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 08/22/2020
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: 208-847-1630
  • Fax: 208-847-2201
Mailing address:
  • Phone: 208-847-1630
  • Fax: 208-847-2201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number35
License Number StateID

VIII. Authorized Official

Name: MR. RODNEY JACOBSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 208-847-4402