NPIMap

Organization Active NPI

State of Idaho

Doing business as State Hospital South Group

  • Psychologist
  • Blackfoot, ID
National Provider Identifier
1053615260
Registry record updated Jan 3, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
PsychologistTaxonomy code 103T00000X
License
17 Issued in ID
Legal business name
STATE OF IDAHO
Doing business as
State Hospital South Group
Practice address
700 E Alice St
Blackfoot, ID 83221-4925
Phone
(208) 785-8506
Fax
(208) 785-8518
NPI assigned
Jan 3, 2011
Last updated
Jan 3, 2011By the provider in NPPES
Organization subpart
Yes
Parent organization
STATE HOSPITAL SOUTHAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 3, 2011

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

Authorized official

Name
Lorna B Colvin
Title
Patient Account Specialist
Phone
(208) 785-8506

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
PsychologistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 103T00000X 17 ID Primary

Addresses

Primary practice location

700 E Alice St
Blackfoot, ID 83221-4925

Mailing address

700 E Alice St
PO Box 400
Blackfoot, ID 83221-4925
Phone (208) 785-8506

Other identifiers 3

IdentifierTypeStateIssuer
00844OtherIDBLUE CROSS
1992789101MedicaidID
20315OtherIDREGENCE BLUE SHIELD

Other names 1

  • State Hospital South Group Doing business as

National Provider Directory

National Provider Directory
Tax ID family
State of Idaho Dept Health114 organizations share this tax ID, including this one
Part of
State Hosp So Clinic

Organizations with this tax ID in the same state 17

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 17

Locations

700 E Alice St
Blackfoot, ID 83221
Phone (208) 758-1200

NPI Registry JSON

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

{
    "created_epoch": "1294012800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1294012800000",
    "number": "1053615260",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "700 E ALICE ST",
            "address_2": "PO BOX 400",
            "city": "BLACKFOOT",
            "state": "ID",
            "postal_code": "832214925",
            "telephone_number": "208-785-8506",
            "fax_number": "208-785-8518"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "700 E ALICE ST",
            "city": "BLACKFOOT",
            "state": "ID",
            "postal_code": "832214925",
            "telephone_number": "208-785-8506",
            "fax_number": "208-785-8518"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "STATE OF IDAHO",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "STATE HOSPITAL SOUTH",
        "enumeration_date": "2011-01-03",
        "last_updated": "2011-01-03",
        "status": "A",
        "authorized_official_last_name": "COLVIN",
        "authorized_official_first_name": "LORNA",
        "authorized_official_middle_name": "B",
        "authorized_official_title_or_position": "PATIENT ACCOUNT SPECIALIST",
        "authorized_official_telephone_number": "208-785-8506"
    },
    "taxonomies": [
        {
            "code": "103T00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Psychologist",
            "state": "ID",
            "license": "17",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS",
            "identifier": "00844",
            "state": "ID"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1992789101",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "REGENCE BLUE SHIELD",
            "identifier": "20315",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "State Hospital South Group",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Blackfoot, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 3, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.