Bear Lake County Memorial Hospital
Organization Active NPI Internal Medicine Physician · Montpelier, ID
NPI 1174741441 · NPPES record last updated Dec 17, 2012
Key facts
- NPI
- 1174741441
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Internal Medicine Physician 207R00000X
- License
- M7743 (ID)
- Legal business name
- BEAR LAKE COUNTY MEMORIAL HOSPITAL
- Practice address
- 166 S 5TH St
Montpelier, ID 83254-1557 - Phone
- (208) 847-1110
- Fax
- (208) 847-0228
- NPI assigned
- Apr 23, 2007
- Organization subpart
- No
Authorized official
- Name
- Laurie Bingham
- Title
- Contract Management
- Phone
- (208) 847-4327
Owners & managing parties with NPI records 7
Owned or controlled facilities with NPI records 2
Other NPIs on the same Medicare enrollment 4
Other NPIs with the same Medicare PAC ID 7
Related certifications (CCN) 1
Facilities with the same owner 2
Practitioners 44
-
Anya Michelle Anthony, P.A.C.
-
Alex Michael Carr, FNP
-
Peter Melvin Crane, M.D.
-
Jennifer Felter, NP
-
Brandon J. Henscheid, PSY.D.
-
Trevor Dean Jacobson, M.D.
-
Ryan Bradley Longmore, D.O.
-
Alex C Moss, PAC
-
Houston Reynolds, MD
-
Shaun David Tobler, MSW, LCSW
-
Kasey L Ward, NP
-
Wayne Berg, FNP
-
Mark Cowan, MD
-
Adam Kimball Franson, D.O.
-
Jonah Jess Green, MD
-
Kerry Glen Jepsen, M.D.
-
Ryan P McDonald, MD
-
Benjamin Olson, DO
-
John Howard Pymm, D.O.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 13D0890013 | Bear Lake Internal Medicine | Provider-performed microscopy | Aug 9, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in ID
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
- Other · Non-profit
- Enrollment address
- 166 South Fifth Street
Montpelier, ID 83254-1557 - Related CCNs
- 131316
All disclosed owners & managing parties 4
| Name | Role | Since | Share |
|---|---|---|---|
| Rodney Dean Jacobson |
Corporate Officer |
Jun 10, 2013 | |
| W-2 Managing Employee |
Jun 10, 2013 | ||
| Arel Hunt |
W-2 Managing Employee | Jan 1, 2023 | |
| Leslie Crane |
Corporate Officer |
Jun 10, 2013 | |
| W-2 Managing Employee |
Jun 10, 2013 | ||
| Bear Lake County Memorial Hospital |
5% Or Greater Direct Ownership Interest | Jan 1, 1966 | 100% |
All facility ownership & control disclosures 2
| Facility | Type | Role | Since |
|---|---|---|---|
| Bear Lake Memorial Skilled Nursing Facility |
Skilled nursing facility | Operational/Managerial Control Direct Ownership Interest (100%) |
May 1, 1977 May 1, 1977 |
| Bear Lake County Memorial Hospital Home Health |
Home health agency | Operational/Managerial Control (100%) | Dec 14, 1993 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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 |
National Provider Directory
Locations
166 S 5th St
Montpelier, ID 83254
Phone (208) 847-1110
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Internal Medicine Physician |
207R00000X | M7743 | ID | Yes |
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 identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 806833500 | Medicaid | ID |
Other names
- BEAR LAKE INTERNAL MEDICINE
Other providers in Montpelier, ID
- Anya Michelle Anthony
- Trezlyn Bartschi
- Bear Lake Community Health Center, Inc.
- Bear Lake County
- Bear Lake County Memorial Hospital
- Bear Lake County Memorial Hospital
- Bear Lake County Memorial Hospital
- Bear Lake County Memorial Hospital
- Bear Lake County Memorial Hospital
All providers in Montpelier, ID · Internal Medicine Physician in Idaho
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 17, 2012. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.