NPIMap

Organization Active NPI

Shoshone Bannock Tribes, Inc

Doing business as Shoshone-Bannock Community Health Center

  • Clinic/Center
  • Fort Hall, ID
National Provider Identifier
1225414519
Registry record updated Jan 19, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic/CenterTaxonomy code 261Q00000X
Legal business name
SHOSHONE BANNOCK TRIBES, INC
Doing business as
Shoshone-Bannock Community Health Center
Practice address
Navajo Drive BLDG 70
Fort Hall, ID 83203-0306
Phone
(208) 478-3995
Fax
(208) 478-4040
NPI assigned
Aug 10, 2015
Last updated
Jan 19, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 19, 2022

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

Authorized official

Name
Melissa M Johnson
Title
Credentialing Manager
Phone
(517) 896-3464

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X NU Primary
Federally Qualified Health Center (FQHC) 261QF0400X NU

Addresses

Primary practice location

Navajo Drive BLDG 70
Fort Hall, ID 83203-0306

Mailing address

PO Box 306
Fort Hall, ID 83203-0306
Phone (208) 478-3995

Other identifiers 1

IdentifierTypeStateIssuer
1225414519MedicaidID

Other names 1

  • Shoshone-Bannock Community Health Center Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL VPN Health Information Exchange (HIE)

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20190619001470 TX Part B Supplier - Clinic/Group Practice 5496804429 Receives reassigned benefits from 11 practitioners
1 other NPI on this enrollment
Practice locations: Fort Hall, ID

Other NPIs with the same Medicare PAC ID 1

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.

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 15

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 15

NPI Registry JSON

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

{
    "created_epoch": "1439164800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1642550400000",
    "number": "1225414519",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 306",
            "city": "FORT HALL",
            "state": "ID",
            "postal_code": "832030306",
            "telephone_number": "208-478-3995",
            "fax_number": "208-478-4040"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "NAVAJO DRIVE BLDG 70",
            "city": "FORT HALL",
            "state": "ID",
            "postal_code": "832030306",
            "telephone_number": "208-478-3995",
            "fax_number": "208-478-4040"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOSHONE BANNOCK TRIBES, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-08-10",
        "last_updated": "2022-01-19",
        "certification_date": "2022-01-19",
        "status": "A",
        "authorized_official_last_name": "JOHNSON",
        "authorized_official_first_name": "MELISSA",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "CREDENTIALING MANAGER",
        "authorized_official_telephone_number": "517-896-3464"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1225414519",
            "state": "ID"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "VPN",
            "affiliation": "N",
            "use": "HIE",
            "useDescription": "Health Information Exchange (HIE)",
            "address_1": "Navajo Drive Bldg 70",
            "city": "Fort Hall",
            "state": "ID",
            "country_code": "US",
            "postal_code": "832030306",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Shoshone-Bannock Community Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fort Hall, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 19, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.