Healthcare Provider Details

I. General information

NPI: 1114010782
Provider Name (Legal Business Name): REXBURG MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

393 E 2ND N
REXBURG ID
83440
US

IV. Provider business mailing address

393 E 2ND N
REXBURG ID
83440
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-5401
  • Fax: 208-356-3111
Mailing address:
  • Phone: 208-356-5401
  • Fax: 208-356-3111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM4211
License Number StateID

VIII. Authorized Official

Name: MRS. MARY ZOLLINGER
Title or Position: ADMINISTRATOR
Credential:
Phone: 208-356-5401