Healthcare Provider Details

I. General information

NPI: 1912555319
Provider Name (Legal Business Name): MOUNT CARMEL HEALTH PLAN OF IDAHO, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2019
Last Update Date: 01/06/2023
Certification Date: 01/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 EASTON SQUARE PLACE SUITE 300 - HEALTH PLAN
COLUMBUS OH
43219
US

IV. Provider business mailing address

6150 E BROAD ST
COLUMBUS OH
43213-1574
US

V. Phone/Fax

Practice location:
  • Phone: 614-546-4651
  • Fax: 614-546-4106
Mailing address:
  • Phone: 614-546-4651
  • Fax: 614-546-4106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: MRS. TRISHA WHETSTONE
Title or Position: ASSOCIATE COUNSEL
Credential: ESQ.
Phone: 614-546-4651