Healthcare Provider Details

I. General information

NPI: 1942567847
Provider Name (Legal Business Name): GRITMAN MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2012
Last Update Date: 10/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 S MAIN ST
TROY ID
83871-0415
US

IV. Provider business mailing address

700 S MAIN ST
MOSCOW ID
83843-3056
US

V. Phone/Fax

Practice location:
  • Phone: 208-835-5550
  • Fax: 208-883-6580
Mailing address:
  • Phone: 208-882-4511
  • Fax: 208-883-6571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. PATRICK MCCONNELL
Title or Position: CFO
Credential:
Phone: 208-883-2220