| Shoshone Bannock Clinic | |
|
717 Mission Road Fort Hall ID 83203-0306 | |
| (208) 238-2400 | |
| (208) 238-5462 |
| Full Name | Shoshone Bannock Clinic |
|---|---|
| Speciality | Clinic/Center |
| Location | 717 Mission Road, Fort Hall, Idaho |
| Authorized Official Name and Position | Angela Mendez (TRIBAL HEALTH DIRECTOR) |
| Authorized Official Contact | 2084783744 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Shoshone Bannock Clinic Po Box 306 Fort Hall ID 83203-0306 Ph: (208) 238-2400 | Shoshone Bannock Clinic 717 Mission Road Fort Hall ID 83203-0306 Ph: (208) 238-2400 |
| NPI Number | 1801949763 |
|---|---|
| Provider Enumeration Date | 01/22/2007 |
| Last Update Date | 01/25/2010 |
| Medicare PECOS PAC ID | 5496804429 |
|---|---|
| Medicare Enrollment ID | O20100330001318 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1801949763 | NPI | - | NPPES |
| 002264100 | Medicaid | ID | |
| 003399100 | Medicaid | ID | |
| 8063500 | Medicaid | ID | |
| 8064977 | Medicaid | ID | |
| 806648600 | Medicaid | ID | |
| 80662922 | Medicaid | ID |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261Q00000X | Clinic/center | (* (Not Available)) | Primary |
| Provider Name | Deric V Ravsten |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1154431542 PECOS PAC ID: 4688636129 Enrollment ID: I20041027001257 |
| Provider Name | Kelly Palmer |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1184780694 PECOS PAC ID: 5991879892 Enrollment ID: I20080809000124 |
| Provider Name | Kristy Lee Broncho |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1932323045 PECOS PAC ID: 8729116009 Enrollment ID: I20100506000496 |
| Provider Name | Jessie A Marshall |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1750507604 PECOS PAC ID: 5193854727 Enrollment ID: I20100520000176 |
| Provider Name | Douglas S Williams |
|---|---|
| Provider Type | Practitioner - Podiatry |
| Provider Identifiers | NPI Number: 1932106713 PECOS PAC ID: 3971636473 Enrollment ID: I20100811000339 |
| Provider Name | Kathleen A Baron |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1164864724 PECOS PAC ID: 6800026329 Enrollment ID: I20140303000941 |
| Provider Name | Daniel L Traughber |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1386944411 PECOS PAC ID: 9234352741 Enrollment ID: I20141104002644 |
| Provider Name | Natalia A Sorensen |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1841620085 PECOS PAC ID: 1254655079 Enrollment ID: I20150126001453 |
| Provider Name | Patricia Stadler |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1124569108 PECOS PAC ID: 0446537526 Enrollment ID: I20170426002519 |
| Provider Name | Titus Kener |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1356876551 PECOS PAC ID: 4183994346 Enrollment ID: I20170720000546 |
| Provider Name | Rachel E Peay-goodman |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1164941803 PECOS PAC ID: 3072871946 Enrollment ID: I20171222001184 |
| Provider Name | Jesse Tellez Hernandez |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1184099558 PECOS PAC ID: 5395080543 Enrollment ID: I20181217003059 |
Fort Hall Indian Health Services Primary Care Clinic Medicare: Not Enrolled in Medicare Practice Location: Mission Rd, Fort Hall, ID 83203 Phone: 208-238-2400 Fax: 208-238-5463 | |
Shoshone-bannock Community Health Center Primary Care Clinic Medicare: Medicare Enrolled Practice Location: Navajo Drive Bldg 70, Fort Hall, ID 83203 Phone: 208-478-3995 Fax: 208-478-4040 | |
Not-tsoo Gah-nee Indian Health Center Primary Care Clinic Medicare: Not Enrolled in Medicare Practice Location: 717 Mission Road, Fort Hall, ID 83203 Phone: 208-238-5400 |