Basic Information
| Provider Information | |||||||||
| NPI: | 1801945225 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH IDAHO CANCER CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2003 LINCOLN WAY | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086663808 | ||||||||
| FaxNumber: | 2086663963 | ||||||||
| Practice Location | |||||||||
| Address1: | 2003 LINCOLN WAY | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086663808 | ||||||||
| FaxNumber: | 2086663963 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MICHELS | ||||||||
| AuthorizedOfficialFirstName: | MELANIE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | TECHNICAL LIAISON | ||||||||
| AuthorizedOfficialTelephone: | 2086662219 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QX0200X | 42 | ID | Y | Ambulatory Health Care Facilities | Clinic/Center | Oncology |
ID Information
| ID | Type | State | Issuer | Description | 00257 | 01 | ID | BLUE CROSS | OTHER | 000010004925 | 01 | ID | REGENCE BLUE SHIELD | OTHER |