=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356438816
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRITMAN MEDICAL CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2006
-----------------------------------------------------
Last Update Date | 02/14/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 156 6TH ST
-----------------------------------------------------
City | POTLATCH
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83855
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-875-2380
-----------------------------------------------------
Fax | 208-875-2303
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 S MAIN ST
-----------------------------------------------------
City | MOSCOW
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-882-4511
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MRS. KARA L BESST
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-883-2220
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number | 39
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------