Basic Information
Provider Information | |||||||||
NPI: | 1407172059 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KOOTENAI URGENT CARE LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 700 W IRONWOOD DR | ||||||||
Address2: | SUITE 272E | ||||||||
City: | COEUR D ALENE | ||||||||
State: | ID | ||||||||
PostalCode: | 838142656 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2086760102 | ||||||||
FaxNumber: | 2086760147 | ||||||||
Practice Location | |||||||||
Address1: | 566 W PRAIRIE AVE | ||||||||
Address2: |   | ||||||||
City: | COEUR D ALENE | ||||||||
State: | ID | ||||||||
PostalCode: | 838157766 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2087729110 | ||||||||
FaxNumber: | 2087720590 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/07/2010 | ||||||||
LastUpdateDate: | 03/22/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KOELSCH | ||||||||
AuthorizedOfficialFirstName: | ERIC | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 2086760145 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363L00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1369049 | 01 | ID | MEDICARE PART B PTAN | OTHER | DQ3168 | 01 | ID | RAILROAD MEDICARE | OTHER |