Healthcare Provider Details

I. General information

NPI: 1760610935
Provider Name (Legal Business Name): POCATELLO HOSPITAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2009
Last Update Date: 04/19/2022
Certification Date: 04/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651 MEMORIAL DR
POCATELLO ID
83201-4071
US

IV. Provider business mailing address

651 MEMORIAL DR
POCATELLO ID
83201-4071
US

V. Phone/Fax

Practice location:
  • Phone: 208-239-2110
  • Fax: 208-239-2145
Mailing address:
  • Phone: 208-239-2110
  • Fax: 208-239-2145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number12
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN C. PETROVICH
Title or Position: EVP, GENERAL COUNSEL
Credential:
Phone: 615-296-3594