Basic Information
| Provider Information | |||||||||
| NPI: | 1881100097 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST GASTROENTEROLOGY, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2156 EAGLECREST DR | ||||||||
| Address2: | |||||||||
| City: | FILER | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833285068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035053628 | ||||||||
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| Practice Location | |||||||||
| Address1: | 526 SHOUP AVE W | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833016050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087367620 | ||||||||
| FaxNumber: | 8558304058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2017 | ||||||||
| LastUpdateDate: | 06/19/2020 | ||||||||
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| AuthorizedOfficialLastName: | CSANKY | ||||||||
| AuthorizedOfficialFirstName: | JUDITH | ||||||||
| AuthorizedOfficialMiddleName: | ERIKA | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5035053628 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | M-11559 | ID | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.