NPIMap

Organization Active NPI

Two Rivers Medical Clinic, PA

  • Rural Health Clinic/Center
  • Weiser, ID
National Provider Identifier
1376662486
Registry record updated Apr 12, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
TWO RIVERS MEDICAL CLINIC, PA
Practice address
683 E 3Rd St
Weiser, ID 83672-2248
Phone
(208) 549-0211
Fax
(208) 549-0104
NPI assigned
Mar 28, 2007
Last updated
Apr 12, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 12, 2016

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

Authorized official

Name
Tony Edmondson
Title
Clinic Administrator
Phone
(208) 549-0211

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

683 E 3Rd St
Weiser, ID 83672-2248

Mailing address

PO Box 871
Weiser, ID 83672-0001
Phone (208) 549-0211

Other identifiers 4

IdentifierTypeStateIssuer
002756300MedicaidID
805040300MedicaidID
002756600MedicaidID
1376662486MedicaidID

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040428001375 ID Part B Supplier - Clinic/Group Practice 8628065950 Receives reassigned benefits from 6 practitioners
Practice locations: Weiser, ID
O20101012000599 ID Part A Provider - Rural Health Clinic 8628065950 Practice locations: Weiser, ID

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1376662486. Details of each certification follow.

Rural health clinic certification: CCN 133836

Legal name
TWO RIVERS MEDICAL CLINIC, PA
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Apr 1, 1998
Last certification
Jan 9, 2003
Ownership / control type
1B
Organization structure
CorporationProprietary
Incorporated
Feb 1, 1995 in ID
Enrollment address
683 E 3Rd St
Weiser, ID 83672-2248

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
13D0521438Two Rivers Medical Clinic PA683 E 3Rd St, Weiser, ID 83672Provider-performed microscopyJan 18, 2027

National Provider Directory

National Provider Directory

Locations

683 E 3rd St
Weiser, ID 83672
Phone (208) 549-0211

Ownership & related parties

All disclosed owners & managing parties 2

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

NameRoleSinceShare
Michele Rae Johnson Individual Corporate OfficerSecretary Jul 1, 2017
W-2 Managing EmployeeClinic Administrator Jul 1, 2017
Lore B Wootton Individual 5% Or Greater Direct Ownership Interest Mar 1, 1998

Owners & managing parties with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 6

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.

NPI Registry JSON

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

{
    "created_epoch": "1175040000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1460419200000",
    "number": "1376662486",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 871",
            "city": "WEISER",
            "state": "ID",
            "postal_code": "836720001",
            "telephone_number": "208-549-0211",
            "fax_number": "208-549-0104"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "683 E 3RD ST",
            "city": "WEISER",
            "state": "ID",
            "postal_code": "836722248",
            "telephone_number": "208-549-0211",
            "fax_number": "208-549-0104"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TWO RIVERS MEDICAL CLINIC, PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-28",
        "last_updated": "2016-04-12",
        "status": "A",
        "authorized_official_last_name": "EDMONDSON",
        "authorized_official_first_name": "TONY",
        "authorized_official_title_or_position": "CLINIC ADMINISTRATOR",
        "authorized_official_telephone_number": "208-549-0211"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "002756300",
            "state": "ID"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "805040300",
            "state": "ID"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "002756600",
            "state": "ID"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1376662486",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Weiser, ID

Sources for this page

Verify at the official NPI Registry.