1639116452 NPI number — SPOKANE CARDIOLOGY PS

Table of content: (NPI 1639116452)

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:
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:
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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