NPIMap

Organization Active NPI

Bear Lake County Memorial Hospital

Doing business as Bear Lake Internal Medicine

  • Internal Medicine Physician
  • Montpelier, ID
National Provider Identifier
1174741441
Registry record updated Dec 17, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
M7743 Issued in ID
Legal business name
BEAR LAKE COUNTY MEMORIAL HOSPITAL
Doing business as
Bear Lake Internal Medicine
Practice address
166 S 5TH St
Montpelier, ID 83254-1557
Phone
(208) 847-1110
Fax
(208) 847-0228
NPI assigned
Apr 23, 2007
Last updated
Dec 17, 2012By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 17, 2012

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

Authorized official

Name
Laurie Bingham
Title
Contract Management
Phone
(208) 847-4327

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X M7743 ID Primary

Addresses

Primary practice location

166 S 5TH St
Montpelier, ID 83254-1557

Mailing address

166 S 5TH St
Montpelier, ID 83254-1557
Phone (208) 847-1110

Other names 1

  • BEAR LAKE INTERNAL MEDICINE Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050429000989 ID Part A Provider - Rural Health Clinic 5395799860 Practice locations: Montpelier, ID
O20071003000677 ID Part B Supplier - Clinic/Group Practice 5395799860 Receives reassigned benefits from 37 practitioners
4 other NPIs on this enrollment
Practice locations: Soda Springs, ID; Preston, ID; Montpelier, ID

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1174741441. Details of each certification follow.

Rural health clinic certification: CCN 138505

Legal name
BEAR LAKE COUNTY MEMORIAL HOSPITAL
Doing business as
BEAR LAKE INTERNAL MEDICINE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Feb 13, 2004
Last certification
Feb 13, 2004
Ownership / control type
Non-profit – church related
Organization structure
OtherNon-profit
Enrollment address
166 South Fifth Street
Montpelier, ID 83254-1557
Related CCNs
131316

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

Other NPIs with the same Medicare PAC ID 7

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

Other NPIs on the same Medicare enrollment 4

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
13D0890013Bear Lake Internal Medicine166 S 5TH St, Montpelier, ID 83254Provider-performed microscopyAug 9, 2026

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 4

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

NameRoleSinceShare
Rodney Dean Jacobson Individual Corporate OfficerCeo Jun 10, 2013
W-2 Managing EmployeeCeo Jun 10, 2013
Arel Hunt Individual W-2 Managing Employee Jan 1, 2023
Leslie Crane Individual Corporate OfficerCfo Jun 10, 2013
W-2 Managing EmployeeCfo Jun 10, 2013
Bear Lake County Memorial Hospital Organization, Montpelier, ID 5% Or Greater Direct Ownership Interest Jan 1, 1966 100%

Owners & managing parties with NPI records 7

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

All facility ownership & control disclosures 2

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

FacilityTypeRoleSince
Bear Lake Memorial Skilled Nursing FacilityMontpelier, ID, CCN 135070 Skilled nursing facility Operational/Managerial Control
Direct Ownership Interest (100%)		 May 1, 1977
May 1, 1977
Bear Lake County Memorial Hospital Home HealthMontpelier, ID, CCN 137069 Home health agency Operational/Managerial Control (100%) Dec 14, 1993

Owned or controlled facilities with NPI records 2

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

Facilities with the same owner 2

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

Practitioners & affiliated clinicians

Practitioners 39

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 39

NPI Registry JSON

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

{
    "created_epoch": "1177286400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1355702400000",
    "number": "1174741441",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "166 S 5TH ST",
            "city": "MONTPELIER",
            "state": "ID",
            "postal_code": "832541557",
            "telephone_number": "208-847-1110",
            "fax_number": "208-847-0228"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "166 S 5TH ST",
            "city": "MONTPELIER",
            "state": "ID",
            "postal_code": "832541557",
            "telephone_number": "208-847-1110",
            "fax_number": "208-847-0228"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BEAR LAKE COUNTY MEMORIAL HOSPITAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-23",
        "last_updated": "2012-12-17",
        "status": "A",
        "authorized_official_last_name": "BINGHAM",
        "authorized_official_first_name": "LAURIE",
        "authorized_official_title_or_position": "CONTRACT MANAGEMENT",
        "authorized_official_telephone_number": "208-847-4327"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": "ID",
            "license": "M7743",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "BEAR LAKE INTERNAL MEDICINE",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Montpelier, ID

Sources for this page

Verify at the official NPI Registry.