Basic Information
| Provider Information | |||||||||
| NPI: | 1962440966 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANESTHESIA ASSOCIATES OF COEUR D ALENE PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 35145 #40023 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981245145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254071500 | ||||||||
| FaxNumber: | 4254071112 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 W IRONWOOD DR STE 250 | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838141415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087658585 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 01/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | PAYNE | ||||||||
| AuthorizedOfficialFirstName: | ERIK | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 2087658585 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 01/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | CE9560 | 01 | ID | RR MEDICARE GRP NUMBER | OTHER | 000010017887 | 01 | ID | REGENCE B/S GROUP NUMBER | OTHER | 8B016 | 01 | ID | BLUE CROSS IDAHO GROUP # | OTHER |