NPIMap

Organization Active NPI

Benewah Medical Center

  • Federally Qualified Health Center (FQHC)
  • Plummer, ID
National Provider Identifier
1336135136
Registry record updated Mar 29, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
131814 Issued in ID
Legal business name
BENEWAH MEDICAL CENTER
Practice address
427 N 12TH St
Plummer, ID 83851
Phone
(208) 686-1931
NPI assigned
Sep 27, 2005
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 29, 2018

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

Authorized official

Name
Paul Leroy Bergland
Title
Chief Financial Officer
Phone
(208) 686-5162

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 131814 ID Primary

Addresses

Primary practice location

427 N 12TH St
Plummer, ID 83851

Mailing address

PO Box 388
Plummer, ID 83851-0388
Phone (208) 686-1931

Other identifiers 3

IdentifierTypeStateIssuer
0026771MedicaidID
805801300MedicaidID
804166900MedicaidID

Other names 1

  • Marimn Health Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040331001566 ID Part B Supplier - Clinic/Group Practice 6709878622 Receives reassigned benefits from 34 practitioners
Practice locations: Plummer, ID
O20100726000118 ID Part A Provider - Federally Qualified Health Center (FQHC) 6709878622 Practice locations: Plummer, ID

Federally qualified health center certification: CCN 131814

Legal name
BENEWAH MEDICAL CENTER
Doing business as
MARIMN HEALTH
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 1, 1994
Last certification
May 1, 1994
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Enrollment address
427 N 12TH St
Plummer, ID 83851-0388

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 3

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

NameRoleSinceShare
Charlene D Way Individual W-2 Managing EmployeeRevenue Manager Feb 1, 2017 100%
Coeur D'Alene Tribe Organization, Plummer, ID Operational/Managerial Control Sep 7, 2010
Paul Bergland Individual W-2 Managing EmployeeCfo Feb 1, 2017 100%

Practitioners & affiliated clinicians

Practitioners 40

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 40

NPI Registry JSON

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

{
    "created_epoch": "1127779200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1522281600000",
    "number": "1336135136",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 388",
            "city": "PLUMMER",
            "state": "ID",
            "postal_code": "838510388",
            "telephone_number": "208-686-1931",
            "fax_number": "208-686-1146"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "427 N 12TH ST",
            "city": "PLUMMER",
            "state": "ID",
            "postal_code": "83851",
            "telephone_number": "208-686-1931"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BENEWAH MEDICAL CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-09-27",
        "last_updated": "2018-03-29",
        "status": "A",
        "authorized_official_last_name": "BERGLAND",
        "authorized_official_first_name": "PAUL",
        "authorized_official_middle_name": "LEROY",
        "authorized_official_title_or_position": "CHIEF FINANCIAL OFFICER",
        "authorized_official_telephone_number": "208-686-5162"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "ID",
            "license": "131814",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0026771",
            "state": "ID"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "805801300",
            "state": "ID"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "804166900",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Marimn Health",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Marimn Health",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Plummer, ID

Sources for this page

Verify at the official NPI Registry.