Healthcare Provider Details

I. General information

NPI: 1386041119
Provider Name (Legal Business Name): GRITMAN MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2014
Last Update Date: 10/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S MAIN ST
MOSCOW ID
83843-3056
US

IV. Provider business mailing address

700 S MAIN ST
MOSCOW ID
83843-3056
US

V. Phone/Fax

Practice location:
  • Phone: 208-882-4511
  • Fax: 208-883-6580
Mailing address:
  • Phone: 208-882-4511
  • Fax: 208-883-6580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number39
License Number StateID

VIII. Authorized Official

Name: PATRICK MCCONNELL
Title or Position: CFO
Credential:
Phone: 208-883-2220