Healthcare Provider Details

I. General information

NPI: 1831179696
Provider Name (Legal Business Name): ELMORE MEDICAL CENTER HOSPITAL DISTRICT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 MCKENNA DR
MOUNTAIN HOME ID
83647-2143
US

IV. Provider business mailing address

465 MCKENNA DR
MOUNTAIN HOME ID
83647-2143
US

V. Phone/Fax

Practice location:
  • Phone: 208-587-9703
  • Fax: 208-580-9812
Mailing address:
  • Phone: 208-587-9703
  • Fax: 208-580-9812

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: MR. GREG MAUER
Title or Position: CEO
Credential:
Phone: 208-580-2677