Provider Demographics
NPI:1144287756
Name:BONNER GENERAL HOSPITAL, INC.
Entity type:Organization
Organization Name:BONNER GENERAL HOSPITAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHERYL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:RICKARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-265-1100
Mailing Address - Street 1:520 N 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1507
Mailing Address - Country:US
Mailing Address - Phone:208-265-1101
Mailing Address - Fax:208-265-1277
Practice Address - Street 1:520 N 3RD AVE
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1507
Practice Address - Country:US
Practice Address - Phone:208-265-1101
Practice Address - Fax:208-265-1277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID22282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010004580OtherREGENCE BLUE SHIELD 1500
ID002406400Medicaid
ID000010004581OtherREGENCE BLUE SHIELD 1500
ID002274000Medicaid
WA3300423Medicaid
WA7027337Medicaid
ID000010004582OtherREGENCE BLUE SHIELD
WA7106958Medicaid
ID8K388OtherBLUE CROSS 1500
ID000010004583OtherREGENCE BLUE SHIELD UB92
MT0410280Medicaid
ID00067OtherBLUE CROSS UB92
WA0027647OtherDEPT OF LABOR UB92
MT0354783Medicaid
WA0146625OtherDEPT OF LABOR 1500
IDH5337Medicare ID - Type UnspecifiedRAILROAD 1500
MT0410280Medicaid
ID002406400Medicaid
ID002274000Medicaid