MEDICARE: ST. MARY'S HOSPITAL

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	363LF0000X	Family Nurse Practitioner		ID
2	207Q00000X	Family Medicine Physician		ID

General Provider Information

NPI Number	:	1710203237
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. MARY'S HOSPITAL

Provider Business Mailing Address
First Line	:	617 W NORTH ST
Second Line	:
City	:	GRANGEVILLE
State	:	ID
Zip	:	83530-1239
Country	:	US
Telephone Number	:	208-962-3267
Fax Number	:	208-962-2313

Provider Business Practice Location Address
First Line	:	617 W NORTH ST
Second Line	:
City	:	GRANGEVILLE
State	:	ID
Zip	:	83530-1239
Country	:	US
Telephone Number	:	208-962-3267
Fax Number	:	208-962-2313

Authorized Official
Title or Position	:	DIRECTOR OF REVENUE CYCLE
Name	:	MICHELLE M GATES
Credential	:
Telephone Number	:	208-476-8083

Provider Enumeration Date	:	04/08/2010
Last Update Date	:	10/02/2020

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Directions to “ST. MARY'S HOSPITAL ” Practice Location

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