=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376853127
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. JOSEPH REGIONAL MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2010
-----------------------------------------------------
Last Update Date | 10/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 307 SAINT JOHNS WAY
-----------------------------------------------------
City | LEWISTON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83501-2435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-750-7470
-----------------------------------------------------
Fax | 208-799-5713
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 307 SAINT JOHNS WAY
-----------------------------------------------------
City | LEWISTON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83501-2435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-750-7470
-----------------------------------------------------
Fax | 208-799-5713
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SJOC BILLING MANAGER
-----------------------------------------------------
Name | HEATHER D BISHOP
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-683-2928
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------