Basic Information
| Provider Information | |||||||||
| NPI: | 1235288655 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KOOTENAI HEALTH | ||||||||
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| OtherOrganizationName: | KOOTENAI MEDICAL CENTER GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2003 KOOTENAI HEALTH WAY | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838146051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086254000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2003 KOOTENAI HEALTH WAY | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838146051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086254000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 10/02/2020 | ||||||||
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| AuthorizedOfficialLastName: | NESS | ||||||||
| AuthorizedOfficialFirstName: | JON | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2086254000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KOOTENAI HEALTH | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207Y00000X | 42 | ID | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208600000X | 42 | ID | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208800000X | 42 | ID | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 213E00000X | 42 | ID | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 363A00000X | 42 | ID | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | 42 | ID | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207P00000X | 42 | ID | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 805712000 | 05 | ID | MEDICAID | 83758 | 01 | ID | BLUE CROSS | OTHER | 000010004926 | 01 | ID | REGENCE BLUE SHIELD | OTHER | CG7380 | 01 | ID | RR MEDICARE | OTHER |