Basic Information
| Provider Information | |||||||||
| NPI: | 1548299696 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PALOUSE MEDICAL PS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PULLMAN READYCARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 825 SE BISHOP BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | PULLMAN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 991635537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093322517 | ||||||||
| FaxNumber: | 5093349247 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 SE BISHOP BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | PULLMAN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 991635537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093322517 | ||||||||
| FaxNumber: | 5093349247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2006 | ||||||||
| LastUpdateDate: | 08/04/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PERINO | ||||||||
| AuthorizedOfficialFirstName: | LLOYD | ||||||||
| AuthorizedOfficialMiddleName: | EDWIN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5093322517 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7085418 | 05 | WA | MEDICAID | 003202800 | 05 | ID | MEDICAID |