Healthcare Provider Details

I. General information

NPI: 1033737887
Provider Name (Legal Business Name): BONNER GENERAL HOSPITAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2020
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

423 N THIRD AVE STE 210
SANDPOINT ID
83864-1511
US

IV. Provider business mailing address

PO BOX 1343
SANDPOINT ID
83864-0863
US

V. Phone/Fax

Practice location:
  • Phone: 208-265-2221
  • Fax: 208-265-2229
Mailing address:
  • Phone: 208-265-1158
  • Fax: 208-265-1278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN HENNESSY
Title or Position: CEO
Credential:
Phone: 208-265-1100