Basic Information
| Provider Information | |||||||||
| NPI: | 1083607477 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPOKANE RADIATION ONCOLOGY ASSOCIATES P S | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 405 | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992100405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086679334 | ||||||||
| FaxNumber: | 2086642341 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 W IRONWOOD DR | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086663800 | ||||||||
| FaxNumber: | 2086663817 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2005 | ||||||||
| LastUpdateDate: | 12/04/2007 | ||||||||
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| AuthorizedOfficialLastName: | DAVENPORT | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | DELEGATED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 2086663800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | CN8904 | 01 | RAILROAD MEDICARE | OTHER |