Provider Demographics
NPI:1053615260
Name:STATE OF IDAHO
Entity type:Organization
Organization Name:STATE OF IDAHO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PATIENT ACCOUNT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LORNA
Authorized Official - Middle Name:B
Authorized Official - Last Name:COLVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-785-8506
Mailing Address - Street 1:700 E ALICE ST
Mailing Address - Street 2:PO BOX 400
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-4925
Mailing Address - Country:US
Mailing Address - Phone:208-785-8506
Mailing Address - Fax:208-785-8518
Practice Address - Street 1:700 E ALICE ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-4925
Practice Address - Country:US
Practice Address - Phone:208-785-8506
Practice Address - Fax:208-785-8518
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE HOSPITAL SOUTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID17103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID00844OtherBLUE CROSS
ID1992789101Medicaid
ID20315OtherREGENCE BLUE SHIELD
ID00844OtherBLUE CROSS