NPIMap

Organization Active NPI

Pocatello Hospital LLC

Doing business as Portneuf Rehabilitation Center

  • Rehabilitation Hospital Unit
  • Pocatello, ID
National Provider Identifier
1144262114
Registry record updated Apr 19, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rehabilitation Hospital UnitTaxonomy code 273Y00000X
License
H12 Issued in ID
Legal business name
POCATELLO HOSPITAL LLC
Doing business as
Portneuf Rehabilitation Center
Practice address
777 Hospital Way
Pocatello, ID 83201-5175
Phone
(208) 239-1000
Fax
(208) 239-1934
NPI assigned
Jun 12, 2006
Last updated
Apr 19, 2022By the provider in NPPES
Organization subpart
Yes
Parent organization
PORTNEUF MEDICAL CENTERAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Apr 19, 2022

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

Authorized official

Name
Stephen C. Petrovich
Title
Evp, General Counsel
Phone
(615) 296-3594

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rehabilitation Hospital Unit 273Y00000X H12 ID Primary

Addresses

Primary practice location

777 Hospital Way
Pocatello, ID 83201-5175

Mailing address

777 Hospital Way
Pocatello, ID 83201-5175
Phone (208) 239-1000

Other names 1

  • Portneuf Rehabilitation Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20090408000669 ID Part A Provider - Hospital 8527115534 Practice locations: Pocatello, ID
O20090408000685 ID Part A Provider - Hospital 8527115534 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Pocatello, ID

NPI to CCN mapping 2

The Medicare certification numbers (CCNs) connected to NPI 1144262114. Details of each certification follow.

Hospital certification: CCN 13T028

Legal name
POCATELLO HOSPITAL LLC
Doing business as
PORTNEUF MEDICAL CENTER
Organization structure
LLCProprietary
Enrollment address
777 Hospital Way
Pocatello, ID 83201-5175
Hospital Rehabilitation Unit
Hospital subgroups
Rehabilitation unit

Hospital certification: CCN 130028

Legal name
POCATELLO HOSPITAL LLC
Doing business as
PORTNEUF MEDICAL CENTER
Certification status
Active
Provider type (POS)
Hospital – Short-term
Participating since
Jul 1, 1966
Last certification
Nov 7, 2014
Beds
187
Ownership / control type
Private (for profit)
Most recent change of ownership
Feb 1, 2009 (2 total)
Organization structure
LLCProprietary
Enrollment address
777 Hospital Way
Pocatello, ID 83201-5175
Main/Primary Hospital Location
Hospital subgroups
General

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

Other NPIs with the same Medicare PAC ID 2

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

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Care Compare: Hospital

Medicare Care Compare
Listed as
Portneuf Medical CenterCCN 130028 · All quality measures
Overall star rating
4 of 5
Type
Acute Care Hospitals
Ownership
Proprietary
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

Care Compare: Inpatient rehabilitation facility

Medicare Care Compare
Listed as
Portneuf Medical CenterCCN 13T028 · All quality measures
Ownership
For profit
Certified
May 10, 2011

National Provider Directory

National Provider Directory
Part of
Pocatello Hospital LLC

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 13

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

NameRoleSinceShare
Ardent Health Inc Organization, Nashville, TN Corporation 5% Or Greater Indirect Ownership Interest Mar 13, 2017 75.83%
Martin Bonick Individual Corporate OfficerCeo-Chain Office Jan 1, 2022
Corporate OfficerCeo-Chain Office Aug 1, 2020
Pocatello Health System, LLC Organization, Pocatello, ID LLC 5% Or Greater Direct Ownership Interest Feb 1, 2009
5% Or Greater Direct Ownership Interest Feb 1, 2009 98.49%
Mary a Crabtree Individual Corporate OfficerSVP Treasurer Sep 1, 2021
Corporate OfficerSVP Treasurer Jul 1, 2019
LHP Pocatello, LLC Organization, Plano, TX Created for acquisition, LLC, For-profit 5% Or Greater Indirect Ownership Interest Feb 1, 2009 77%
5% Or Greater Indirect Ownership Interest Feb 1, 2009 75.94%
Portneuf Health Trust Inc F/K/a Portneuf Health Care Foundation, Inc Organization, Pocatello, ID Corporation 5% Or Greater Indirect Ownership Interest Feb 1, 2009 23%
5% Or Greater Indirect Ownership Interest Feb 1, 2009 22.68%
LHP Operations Co LLC Organization, Plano, TX LLC, For-profit 5% Or Greater Indirect Ownership Interest Feb 1, 2009 100%
5% Or Greater Indirect Ownership Interest Feb 1, 2009 75.94%
LHP Hospital Group, Inc. Organization, Plano, TX Corporation, For-profit 5% Or Greater Indirect Ownership Interest Feb 1, 2009 100%
5% Or Greater Indirect Ownership Interest Feb 1, 2009 75.94%
Stephen C Petrovich Individual Corporate OfficerGeneral Counsel and Secretary Mar 13, 2017
Matt Maxfield Individual Corporate Officer Jan 1, 2022
W-2 Managing Employee Jan 1, 2022
Ahp Health Partners, Inc Organization, Nashville, TN Corporation 5% Or Greater Indirect Ownership Interest Mar 13, 2017 75.83%
Joseph Alan Deschryver Individual W-2 Managing EmployeeAd; Jan 1, 2025 100%
Ahs Management Company Inc. Organization, Nashville, TN Corporation Operational/Managerial Control Jan 1, 2019 100%

Facilities with the same owner 60

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

View all 60

Practitioners & affiliated clinicians

Affiliated clinicians 533

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

View all 533

NPI Registry JSON

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

{
    "created_epoch": "1150070400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1650326400000",
    "number": "1144262114",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "777 HOSPITAL WAY",
            "city": "POCATELLO",
            "state": "ID",
            "postal_code": "832015175",
            "telephone_number": "208-239-1000",
            "fax_number": "208-239-1934"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "777 HOSPITAL WAY",
            "city": "POCATELLO",
            "state": "ID",
            "postal_code": "832015175",
            "telephone_number": "208-239-1000",
            "fax_number": "208-239-1934"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "POCATELLO HOSPITAL LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PORTNEUF MEDICAL CENTER",
        "enumeration_date": "2006-06-12",
        "last_updated": "2022-04-19",
        "certification_date": "2022-04-19",
        "status": "A",
        "authorized_official_last_name": "PETROVICH",
        "authorized_official_first_name": "STEPHEN",
        "authorized_official_middle_name": "C.",
        "authorized_official_title_or_position": "EVP, GENERAL COUNSEL",
        "authorized_official_telephone_number": "615-296-3594"
    },
    "taxonomies": [
        {
            "code": "273Y00000X",
            "taxonomy_group": "",
            "desc": "Rehabilitation Unit",
            "state": "ID",
            "license": "H12",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Portneuf Rehabilitation Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Portneuf Rehabilitation Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Pocatello, ID

Sources for this page

Verify at the official NPI Registry.