Healthcare Provider Details

I. General information

NPI: 1548450034
Provider Name (Legal Business Name): BMH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2007
Last Update Date: 04/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 HOSPITAL WAY STE D
POCATELLO ID
83201-5091
US

IV. Provider business mailing address

1151 HOSPITAL WAY STE D
POCATELLO ID
83201-5091
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-1451
  • Fax:
Mailing address:
  • Phone: 208-233-1451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: LISA RUDOLPH
Title or Position: PSO SUPPORT SPECIALIST
Credential:
Phone: 208-782-3992