NPIMap

Organization Active NPI

Shoshone Medical Center

  • Critical Access Hospital
  • Kellogg, ID
National Provider Identifier
1043215437
Registry record updated Apr 27, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Critical Access HospitalTaxonomy code 282NC0060X
License
44 Issued in ID
Legal business name
SHOSHONE MEDICAL CENTER
Practice address
25 Jacobs Gulch Rd
Kellogg, ID 83837-2023
Phone
(208) 784-7017
Fax
(208) 786-1019
NPI assigned
Jun 14, 2005
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 27, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Miss Donja Erdman
Title
Cfo
Phone
(208) 784-1221

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Critical Access Hospital 282NC0060X 44 ID Primary

Addresses

Primary practice location

25 Jacobs Gulch Rd
Kellogg, ID 83837-2023

Mailing address

25 Jacobs Gulch Rd
Kellogg, ID 83837-2023
Phone (208) 784-7017

Other identifiers 12

IdentifierTypeStateIssuer
86405OtherIDBLUE CROSS OF IDAHO
3504605OtherMONTANA MEDICAID
002862700MedicaidID
3016300OtherWASHINGTON MEDICAID
0082553OtherWASHINGTON L & I
411320OtherMONTANA MEDICAID
000010000167OtherIDREGENCE
002861700MedicaidID
00513OtherIDBLUE CROSS OF IDAHO
10004OtherWASHINGTON L & I
7043250OtherWASHINGTON MEDICAID
002861800MedicaidID

Other names 1

  • WEST SHOSHONE HOSPITAL DISTRICT Former legal business name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
O20050113001084 ID Part B Supplier - Clinic/Group Practice 6103739107 Receives reassigned benefits from 68 practitioners
Practice locations: Kellogg, ID; Smelterville, ID
O20061104000442 ID Part A Provider - Critical Access Hospital 6103739107 Receives reassigned benefits from 62 practitioners
Practice locations: Kellogg, ID; Smelterville, ID
O20071003000175 ID Part A Provider - Critical Access Hospital 6103739107 Receives reassigned benefits from 2 practitioners
Practice locations: Kellogg, ID

Hospital certification: CCN 131314

Legal name
SHOSHONE MEDICAL CENTER
Certification status
Active
Provider type (POS)
Hospital – Critical access hospital
Participating since
Dec 1, 2000
Last certification
Nov 1, 2012
Beds
25
Ownership / control type
Hospital district or authority
Organization structure
OtherNon-profit
Enrollment address
25 Jacobs Gulch Rd
Kellogg, ID 83837-2023
Main/Primary Hospital Location

Hospital certification: CCN 13Z314

Legal name
SHOSHONE MEDICAL CENTER
Organization structure
OtherNon-profit
Enrollment address
25 Jacobs Gulch Rd
Kellogg, ID 83837-2023
Hospital Swing-Bed Unit

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Care Compare: Hospital

Medicare Care Compare
Listed as
Shoshone Medical CenterCCN 131314
Overall star rating
3 of 5
Type
Critical Access Hospitals
Ownership
Government - Hospital District or Authority
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

National Provider Directory

National Provider Directory

Interoperability endpoints

  • FHIR API: https://fhir-myrecord.cerner.com/r4/9a0a9763-cc6e-4ca0-bdec-c16291c965b9/

Ownership & related parties

All disclosed owners & managing parties 10

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Rick Brooks Individual Corporate DirectorBoard Member Mar 1, 2010
Corporate DirectorBoard Member Mar 2, 2010
Nathan Wendt Individual Corporate DirectorBoard Member May 1, 2007
Frank Smith Individual Corporate DirectorBoard Member Jul 1, 2014
Jerry Cobb Individual Corporate DirectorBoard Member May 1, 1987
Stacie Gilmore Individual W-2 Managing EmployeeRevenue Cycle Analyst Apr 10, 2026
W-2 Managing EmployeeRevenue Cycle Data Anyalyst Apr 16, 2026
John Sanborn Individual Corporate OfficerCeo Jan 5, 2026
Corporate OfficerCeo Jan 5, 2026 100%
Susan Dahlbert Individual Corporate DirectorBoard Member Jun 1, 2005
Donja C Erdman Individual Corporate OfficerCfo May 18, 2026
Corporate OfficerCfo Apr 16, 2026
Andy Helkey Individual Corporate DirectorBoard Member Jun 1, 2019
Shoshone Medical Center Organization, Kellogg, ID 5% Or Greater Direct Ownership Interest Jan 1, 1966 100%
Operational/Managerial Control Jan 1, 1966 100%

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
SMC Family MedicineSmelterville, ID, CCN 138532 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Sep 1, 2020

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 1

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Subparts reporting this organization as parent 2

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

Practitioners & affiliated clinicians

Practitioners 77

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 77

Affiliated clinicians 129

Clinicians who list this facility as an affiliation in Medicare Care Compare.

View all 129

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1118707200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1619481600000",
    "number": "1043215437",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "25 JACOBS GULCH RD",
            "city": "KELLOGG",
            "state": "ID",
            "postal_code": "838372023",
            "telephone_number": "208-784-7017",
            "fax_number": "208-786-1019"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "25 JACOBS GULCH RD",
            "city": "KELLOGG",
            "state": "ID",
            "postal_code": "838372023",
            "telephone_number": "208-784-7017",
            "fax_number": "208-786-1019"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOSHONE MEDICAL CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-06-14",
        "last_updated": "2021-04-27",
        "certification_date": "2021-04-27",
        "status": "A",
        "authorized_official_last_name": "ERDMAN",
        "authorized_official_first_name": "DONJA",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "208-784-1221",
        "authorized_official_name_prefix": "Miss"
    },
    "taxonomies": [
        {
            "code": "282NC0060X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital, Critical Access",
            "state": "ID",
            "license": "44",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS OF IDAHO",
            "identifier": "86405",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MONTANA MEDICAID",
            "identifier": "3504605",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "002862700",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "WASHINGTON MEDICAID",
            "identifier": "3016300",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "WASHINGTON L & I",
            "identifier": "0082553",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MONTANA MEDICAID",
            "identifier": "411320",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "REGENCE",
            "identifier": "000010000167",
            "state": "ID"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "002861700",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS OF IDAHO",
            "identifier": "00513",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "WASHINGTON L & I",
            "identifier": "10004",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "WASHINGTON MEDICAID",
            "identifier": "7043250",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "002861800",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "WEST SHOSHONE HOSPITAL DISTRICT",
            "code": "4",
            "type": "Former Legal Business Name"
        },
        {
            "organization_name": "WEST SHOSHONE HOSPITAL DISTRICT",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Kellogg, ID

Sources for this page

Verify at the official NPI Registry.