1639116452 NPI number — SPOKANE CARDIOLOGY PS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639116452 NPI number — SPOKANE CARDIOLOGY PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPOKANE CARDIOLOGY PS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
KOOTENAI HEART AND VASCULAR HEALTH
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639116452
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
910 W 5TH AVE
Provider Second Line Business Mailing Address:
300
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99204-2966
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-455-8820
Provider Business Mailing Address Fax Number:
509-838-4978

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
910 W 5TH AVE
Provider Second Line Business Practice Location Address:
300
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99204-2966
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-455-8820
Provider Business Practice Location Address Fax Number:
509-838-4978
Provider Enumeration Date:
06/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WICKS
Authorized Official First Name:
CAROLYN
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
509-455-8820

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7826803 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11246 . This is a "L & I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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