MEDICARE: CEDAR MOUNTAIN MEDICAL INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0144814	OTHER	WA	WA DEPT OF LABOR
3	000010014605	OTHER	ID	BLUE SHIELD OF ID
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	03566	OTHER	ID	BLUE CROSS OF IDAHO, GA,

General Provider Information

NPI Number	:	1295748457
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CEDAR MOUNTAIN MEDICAL INC.

Provider Business Mailing Address
First Line	:	PO BOX 3250
Second Line	:
City	:	POST FALLS
State	:	ID
Zip	:	83877-3250
Country	:	US
Telephone Number	:	208-777-9199
Fax Number	:	208-777-8580

Provider Business Practice Location Address
First Line	:	503 E SELTICE WAY STE 8
Second Line	:
City	:	POST FALLS
State	:	ID
Zip	:	83854-6499
Country	:	US
Telephone Number	:	208-777-9199
Fax Number	:	208-777-8580

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. THOMAS PAUL JOHNSON
Credential	:
Telephone Number	:	208-777-9199

Provider Enumeration Date	:	08/15/2006
Last Update Date	:	09/16/2008

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Directions to “CEDAR MOUNTAIN MEDICAL INC. ” Practice Location

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