1881100097 NPI number — NORTHWEST GASTROENTEROLOGY, PLLC

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 1881100097 NPI number — NORTHWEST GASTROENTEROLOGY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST GASTROENTEROLOGY, PLLC
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:
1881100097
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2156 EAGLECREST DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FILER
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83328-5068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-505-3628
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
526 SHOUP AVE W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TWIN FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83301-6050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-736-7620
Provider Business Practice Location Address Fax Number:
855-830-4058
Provider Enumeration Date:
12/26/2017

Additional Information

Authorized Official

Authorized Official Last Name:
CSANKY
Authorized Official First Name:
JUDITH
Authorized Official Middle Name:
ERIKA
Authorized Official Title or Position:
SOLE OWNER
Authorized Official Telephone Number:
503-505-3628

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  M-11559 , 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)





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