1649367889 NPI number — SPOKANE DERMATOLOGY CLINIC 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 1649367889 NPI number — SPOKANE DERMATOLOGY CLINIC PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPOKANE DERMATOLOGY CLINIC 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:
Provider Other Organization Name Type Code:
6
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:
1649367889
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
324 S SHERMAN ST
Provider Second Line Business Mailing Address:
SUITE A1
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99202-1461
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-624-1184
Provider Business Mailing Address Fax Number:
509-625-1449

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
324 S SHERMAN ST
Provider Second Line Business Practice Location Address:
SUITE A1
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99202-1461
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-624-1184
Provider Business Practice Location Address Fax Number:
509-625-1449
Provider Enumeration Date:
10/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DRISCOLL
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
509-624-1184

Provider Taxonomy Codes

  • Taxonomy code: 207ND0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CE1737 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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