Basic Information
Provider Information | |||||||||
NPI: | 1053375105 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MACINERNEY | ||||||||
FirstName: | EDWARD | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2003 KOOTENAI HEALTH WAY | ||||||||
Address2: |   | ||||||||
City: | COEUR D ALENE | ||||||||
State: | ID | ||||||||
PostalCode: | 838146051 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2086255250 | ||||||||
FaxNumber: | 2086255251 | ||||||||
Practice Location | |||||||||
Address1: | 700 W IRONWOOD DR STE 320 | ||||||||
Address2: |   | ||||||||
City: | COEUR D ALENE | ||||||||
State: | ID | ||||||||
PostalCode: | 838144485 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2086255250 | ||||||||
FaxNumber: | 2086255251 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/14/2006 | ||||||||
LastUpdateDate: | 03/22/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/22/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | M-13060 | ID | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 27025013 | 01 | MO | BCBS-KC | OTHER | 060060916 | 01 | MO | RAILROAD MEDICARE | OTHER | 20007804 | 01 |   | MEDICARE | OTHER | 1053375105 | 05 | ID |   | MEDICAID |