Basic Information
| Provider Information | |||||||||
| NPI: | 1629392154 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KOOTENAI URGENT CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 W IRONWOOD DR | ||||||||
| Address2: | SUITE 272E | ||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086760145 | ||||||||
| FaxNumber: | 2086760147 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 E MULLAN AVE | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838546052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087779110 | ||||||||
| FaxNumber: | 2087771871 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2010 | ||||||||
| LastUpdateDate: | 03/22/2012 | ||||||||
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| AuthorizedOfficialLastName: | KOELSCH | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2086760145 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 |