NPIMap

Organization Active NPI

State of Idaho Department of Health and Welfare

Doing business as State Hospital South Medical Clinic

  • Clinic/Center
  • Blackfoot, ID
National Provider Identifier
1538225545
Registry record updated Jul 15, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic/CenterTaxonomy code 261Q00000X
License
17 Issued in ID
Legal business name
STATE OF IDAHO DEPARTMENT OF HEALTH AND WELFARE
Doing business as
State Hospital South Medical Clinic
Practice address
700 E. Alice
Box 400
Blackfoot, ID 83221-0400
Phone
(208) 785-1200
Fax
(208) 785-8518
NPI assigned
Dec 28, 2006
Last updated
Jul 15, 2016By the provider in NPPES
Organization subpart
Yes
Parent organization
STATE HOSPITAL SOUTHAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jul 15, 2016

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

Authorized official

Name
Lynn D Shields
Title
Patient Accounts Specialist
Phone
(208) 785-8462

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X 17 ID Primary

Addresses

Primary practice location

700 E. Alice
Box 400
Blackfoot, ID 83221-0400

Mailing address

700 E. Alice
PO Box 400
Blackfoot, ID 83221-0400
Phone (208) 785-1200

Other identifiers 1

IdentifierTypeStateIssuer
002823200MedicaidID

Other names 1

  • State Hospital South Medical Clinic Doing business as

National Provider Directory

National Provider Directory
Part of
Idaho Dept of Health Welfare Reg II Amh Grangeville

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": "1167264000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1468540800000",
    "number": "1538225545",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "700 E. ALICE",
            "address_2": "PO BOX 400",
            "city": "BLACKFOOT",
            "state": "ID",
            "postal_code": "832210400",
            "telephone_number": "208-785-1200",
            "fax_number": "208-785-8518"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "700 E. ALICE",
            "address_2": "BOX 400",
            "city": "BLACKFOOT",
            "state": "ID",
            "postal_code": "832210400",
            "telephone_number": "208-785-1200",
            "fax_number": "208-785-8518"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "STATE OF IDAHO DEPARTMENT OF HEALTH AND WELFARE",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "STATE HOSPITAL SOUTH",
        "enumeration_date": "2006-12-28",
        "last_updated": "2016-07-15",
        "status": "A",
        "authorized_official_last_name": "SHIELDS",
        "authorized_official_first_name": "LYNN",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "PATIENT ACCOUNTS SPECIALIST",
        "authorized_official_telephone_number": "208-785-8462"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "ID",
            "license": "17",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "002823200",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "State Hospital South Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Blackfoot, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 15, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.