Basic Information
| Provider Information | |||||||||
| NPI: | 1639116452 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPOKANE CARDIOLOGY PS | ||||||||
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| OtherOrganizationName: | KOOTENAI HEART AND VASCULAR HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 910 W 5TH AVE | ||||||||
| Address2: | 300 | ||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992042966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094558820 | ||||||||
| FaxNumber: | 5098384978 | ||||||||
| Practice Location | |||||||||
| Address1: | 910 W 5TH AVE | ||||||||
| Address2: | 300 | ||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992042966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094558820 | ||||||||
| FaxNumber: | 5098384978 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 11/30/2007 | ||||||||
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| AuthorizedOfficialLastName: | WICKS | ||||||||
| AuthorizedOfficialFirstName: | CAROLYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 5094558820 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 7826803 | 05 | WA | MEDICAID | 11246 | 01 | WA | L & I | OTHER |