Basic Information
| Provider Information | |||||||||
| NPI: | 1437326980 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KOOTENAI MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GENERIC ONCOLOGY GROUP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2003 LINCOLN WAY | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086662000 | ||||||||
| FaxNumber: | 2086663963 | ||||||||
| Practice Location | |||||||||
| Address1: | 2003 LINCOLN WAY | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086662000 | ||||||||
| FaxNumber: | 2086663963 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2008 | ||||||||
| LastUpdateDate: | 05/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | MICHELS | ||||||||
| AuthorizedOfficialFirstName: | MELANIE | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | PATIENT ACCOUNT REPRESENTATIVE | ||||||||
| AuthorizedOfficialTelephone: | 2086662219 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KOOTENAI MEDICAL CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 42 | ID | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
No ID Information.