1871562967 NPI number — RUSSELL S VANDERWILDE M.D.

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 1871562967 NPI number — RUSSELL S VANDERWILDE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANDERWILDE
Provider First Name:
RUSSELL
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1871562967
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 W 5TH AVE
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99204-2715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-344-2663
Provider Business Mailing Address Fax Number:
509-624-9179

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 W 5TH AVE
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99204-2715
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-344-2663
Provider Business Practice Location Address Fax Number:
509-624-9179
Provider Enumeration Date:
03/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  MD00030742 , 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: 1083047 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200016187 . This is a "RR MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: K6484 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 3780VA . This is a "ASURIS NW HEALTH" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8919653 . This is a "CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 3283 . This is a "GROUP HEALTH NW" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 000010002357 . This is a "REGENCE BS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 42091 . This is a "DEPT OF LABOR & INDUSTRIE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 003297000 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 379109600 . This is a "OWCP" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com