1427103753 NPI number — EAR, NOSE & THROAT OF COEUR D'ALENE, PA

Table of content: (NPI 1427103753)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427103753 NPI number — EAR, NOSE & THROAT OF COEUR D'ALENE, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAR, NOSE & THROAT OF COEUR D'ALENE, PA
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:
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:
1427103753
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 W IRONWOOD DRIVE
Provider Second Line Business Mailing Address:
SUITE 236
Provider Business Mailing Address City Name:
COEUR D'ALENE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83814-4484
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-765-1345
Provider Business Mailing Address Fax Number:
208-667-9622

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 W IRONWOOD DRIVE
Provider Second Line Business Practice Location Address:
SUITE 236
Provider Business Practice Location Address City Name:
COEUR D'ALENE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83814-4484
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-765-1345
Provider Business Practice Location Address Fax Number:
208-667-9622
Provider Enumeration Date:
01/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KANE
Authorized Official First Name:
SHARI
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
208-765-1345

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 88799 . This is a "BLUE CROSS GROUP #" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 002705200 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000010006189 . This is a "REGENCE GROUP #" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 7125115 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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