NPIMap

Organization Active NPI

Snake River Pediatrics, PC

  • Rural Health Clinic/Center
  • Fruitland, ID
National Provider Identifier
1720489396
Registry record updated Aug 16, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
SNAKE RIVER PEDIATRICS, PC
Practice address
1100 NW 12TH St
Fruitland, ID 83619-5040
Phone
(208) 452-6556
Fax
(541) 216-6557
NPI assigned
Sep 14, 2014
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 16, 2023

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

Authorized official

Name
Matthew Joseph Berria, PHD, PA-CNPI 1982791810
Title
President
Phone
(208) 740-4518

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Primary Care Clinic/Center 261QP2300X PA00913 OR
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

1100 NW 12TH St
Fruitland, ID 83619-5040

Mailing address

1100 NW 12TH St
Fruitland, ID 83619-5040
Phone (208) 452-6556

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20240219001207 ID Part A Provider - Rural Health Clinic 0840513032 Practice locations: Fruitland, ID

Rural health clinic certification: CCN 133862

Legal name
SNAKE RIVER PEDIATRICS PC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Mar 15, 2024
Last certification
Mar 15, 2024
Ownership / control type
1B
Organization structure
CorporationProprietary
Incorporated
Sep 5, 2014 in OR
Enrollment address
1100 NW 12TH St
BLDG a & B
Fruitland, ID 83619-5040

National Provider Directory

National Provider Directory

Locations

1100 NW 12th St
Bldg A
Fruitland, ID 83619
Phone (208) 452-6556

1100 NW 12th St
Fruitland, ID 83619
Phone (208) 452-2662

Ownership & related parties

All disclosed owners & managing parties 6

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

NameRoleSinceShare
Matthew Berria Individual 5% Or Greater Direct Ownership InterestPresident Sep 5, 2014 18.06%
Corporate DirectorPresident Sep 1, 2018
Sage Michele Benintendi M Stringer Individual 5% Or Greater Direct Ownership InterestSecretary Sep 5, 2014 18.06%
Corporate OfficerSecretary Oct 10, 2014
Corporate DirectorHR/Secretary Sep 1, 2018
Chelsey Bidwell Individual Corporate DirectorTreasurer Sep 1, 2018
W-2 Managing EmployeeCeo Oct 10, 2014
Mary L James Individual 5% Or Greater Direct Ownership Interest Sep 5, 2014 18.06%
Corporate OfficerHuman Resource Officer Sep 5, 2014
Corporate DirectorHR/Secretary Sep 1, 2018
Michelle F Devoe Individual 5% Or Greater Direct Ownership InterestMedical Director/VP Sep 5, 2014 24.7%
Corporate DirectorVice President/Medical Director Aug 1, 2023
Chelsie M Lewis Individual 5% Or Greater Direct Ownership InterestSergeant at Arms Sep 5, 2014 18.06%
Corporate DirectorSecretary Sep 1, 2018

Practitioners & affiliated clinicians

Practitioners 13

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

View all 13

NPI Registry JSON

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

{
    "created_epoch": "1410652800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1692144000000",
    "number": "1720489396",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1100 NW 12TH ST",
            "city": "FRUITLAND",
            "state": "ID",
            "postal_code": "836195040",
            "telephone_number": "208-452-6556",
            "fax_number": "541-216-6557"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1100 NW 12TH ST",
            "city": "FRUITLAND",
            "state": "ID",
            "postal_code": "836195040",
            "telephone_number": "208-452-6556",
            "fax_number": "541-216-6557"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SNAKE RIVER PEDIATRICS, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-09-14",
        "last_updated": "2023-08-16",
        "certification_date": "2023-08-16",
        "status": "A",
        "authorized_official_last_name": "BERRIA",
        "authorized_official_first_name": "MATTHEW",
        "authorized_official_middle_name": "JOSEPH",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "208-740-4518",
        "authorized_official_credential": "PHD, PA-C"
    },
    "taxonomies": [
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "OR",
            "license": "PA00913",
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Fruitland, ID

Sources for this page

Verify at the official NPI Registry.