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Bear Lake County Memorial Hospital

Organization Active NPI Rural Health Clinic/Center · Montpelier, ID

NPI 1699057166 · NPPES record last updated Aug 22, 2016

Key facts

NPI
1699057166
Entity type
Organization (NPI type 2)
Primary specialty
Rural Health Clinic/Center 261QR1300X
Legal business name
BEAR LAKE COUNTY MEMORIAL HOSPITAL
Practice address
465 Washington St
Montpelier, ID 83254-1544
Phone
(208) 847-4495
Fax
(208) 847-4336
NPI assigned
Sep 12, 2011
Organization subpart
Yes
Parent organization (as reported)
BEAR LAKE COUNTY MEMORIAL HOSPITAL

Authorized official

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

Owners & managing parties with NPI records 1

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

Owned or controlled facilities with NPI records 3

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

Other NPIs with the same Medicare PAC ID 7

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

Corporate family (same 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.

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

Facilities with the same owner 3

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

Practitioners 35

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

View all 35

Medicare participation

Medicare fee-for-service enrollment
Enrolled in ID

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
Other · Non-profit
Enrollment address
465 Washington St
Montpelier, ID 83254-1544
Related CCNs
131316

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 Officer
Ceo		 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 Officer
Cfo		 Jun 28, 2009
W-2 Managing Employee
Cfo		 Jun 28, 2009
Michael D Blauer
Individual 		W-2 Managing Employee Jan 1, 2022

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 Facility
Montpelier, 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 Health
Montpelier, ID · CCN 137069		 Home health agency Operational/Managerial Control (100%) Dec 14, 1993
Bear Lake Internal Medicine
Montpelier, ID · CCN 138505		 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Jan 1, 1966

Medicare enrollment records

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

National Provider Directory

Tax ID family
Bear Lake County Memorial (10 organizations share this tax ID)
Part of
Bear Lake County Memorial

Locations

455 Washington St
Ste 2
Montpelier, ID 83254
Phone (208) 847-3000

Specialties & licenses

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

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

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

Other providers in Montpelier, ID

All providers in Montpelier, ID · Rural Health Clinic/Center in Idaho

Sources for this page

Verify at the official NPI Registry.