NPIMap

Organization Active NPI

Bear Lake County Memorial Hospital

Doing business as Bear Lake Family Care and OB/GYN

  • Rural Health Clinic/Center
  • Montpelier, ID
National Provider Identifier
1699057166
Registry record updated Aug 22, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
BEAR LAKE COUNTY MEMORIAL HOSPITAL
Doing business as
Bear Lake Family Care and OB/GYN
Practice address
465 Washington St
Montpelier, ID 83254-1544
Phone
(208) 847-4495
Fax
(208) 847-4336
NPI assigned
Sep 12, 2011
Last updated
Aug 22, 2016By the provider in NPPES
Organization subpart
Yes
Parent organization
BEAR LAKE COUNTY MEMORIAL HOSPITALAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 22, 2016

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

Authorized official

Name
Patsy Boehme
Title
Office Manager
Phone
(208) 847-4410

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Obstetrics & Gynecology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207V00000X
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

465 Washington St
Montpelier, ID 83254-1544

Mailing address

465 Washington St
Montpelier, ID 83254-1544
Phone (208) 847-4495

Other names 1

  • Bear Lake Family Care and OB/GYN Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20111128000695 ID Part A Provider - Rural Health Clinic 5395799860 Practice locations: Montpelier, ID

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1699057166. Details of each certification follow.

Rural health clinic certification: CCN 138514

Legal name
BEAR LAKE COUNTY MEMORIAL HOSPITAL
Doing business as
BEAR LAKE FAMILY CARE AND OB/GYN
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Sep 1, 2011
Last certification
Aug 14, 2006
Ownership / control type
Non-profit – church related
Organization structure
OtherNon-profit
Enrollment address
465 Washington St
Montpelier, ID 83254-1544
Related CCNs
131316

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 7

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Bear Lake Mem Hosp Crna10 organizations share this tax ID, including this one
Part of
Bear Lake Mem Hosp Crna

Other organizations with this tax ID 9

Organizations that report the same tax identification number in the National Provider Directory.

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 4

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

NameRoleSinceShare
Rodney Dean Jacobson Individual Corporate OfficerCeo Dec 5, 1984 100%
W-2 Managing Employee Sep 1, 2011
Bear Lake County Organization, Montpelier, ID 5% Or Greater Direct Ownership Interest Sep 1, 2011 100%
Leslie Crane Individual Corporate OfficerCfo Jun 28, 2009
W-2 Managing EmployeeCfo Jun 28, 2009
Michael D Blauer Individual W-2 Managing Employee Jan 1, 2022

Owners & managing parties with NPI records 1

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

  • Bear Lake County

    dba Bear Lake County Ambulance Service

    • Ambulance
    • Montpelier, ID
    • NPI 1447311139

    5% Or Greater Direct Ownership Interest

    CMS ownership

All facility ownership & control disclosures 3

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Bear Lake Memorial Skilled Nursing FacilityMontpelier, ID, CCN 135070 Skilled nursing facility Operational/Managerial Control
Direct Ownership Interest (100%)		 May 1, 1977
May 1, 1977
Bear Lake County Memorial Hospital Home HealthMontpelier, ID, CCN 137069 Home health agency Operational/Managerial Control (100%) Dec 14, 1993
Bear Lake Internal MedicineMontpelier, ID, CCN 138505 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Jan 1, 1966

Owned or controlled facilities with NPI records 3

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 3

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 10

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": "1315785600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1471824000000",
    "number": "1699057166",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "465 WASHINGTON ST",
            "city": "MONTPELIER",
            "state": "ID",
            "postal_code": "832541544",
            "telephone_number": "208-847-4495",
            "fax_number": "208-847-4336"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "465 WASHINGTON ST",
            "city": "MONTPELIER",
            "state": "ID",
            "postal_code": "832541544",
            "telephone_number": "208-847-4495",
            "fax_number": "208-847-4336"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BEAR LAKE COUNTY MEMORIAL HOSPITAL",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "BEAR LAKE COUNTY MEMORIAL HOSPITAL",
        "enumeration_date": "2011-09-12",
        "last_updated": "2016-08-22",
        "status": "A",
        "authorized_official_last_name": "BOEHME",
        "authorized_official_first_name": "PATSY",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "208-847-4410"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Obstetrics & Gynecology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Bear Lake Family Care and OB/GYN",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Montpelier, ID

Sources for this page

Verify at the official NPI Registry.