Basic Information
| Provider Information | |||||||||
| NPI: | 1316250244 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE HEALTH & SERVICES - BOUNDARY COMMUNITY HOSPITAL | ||||||||
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| OtherOrganizationName: | PROVIDENCE SPOKANE HEART INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3776 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981243776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255253030 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6640 KANIKSU ST | ||||||||
| Address2: | OUT PATIENT DEPT. LOWER LEVEL | ||||||||
| City: | BONNERS FERRY | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838057532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098387711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2010 | ||||||||
| LastUpdateDate: | 11/12/2010 | ||||||||
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| AuthorizedOfficialLastName: | REID | ||||||||
| AuthorizedOfficialFirstName: | RANDEE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 4255256694 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.