=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780123950
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BMH, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2017
-----------------------------------------------------
Last Update Date | 12/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3760 WASHINGTON PKWY
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83404-7593
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-535-3637
-----------------------------------------------------
Fax | 208-522-2705
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 98 POPLAR ST
-----------------------------------------------------
City | BLACKFOOT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83221-1758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-782-3969
-----------------------------------------------------
Fax | 208-782-2984
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JACOB ERICKSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-785-3801
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------