Provider Demographics
NPI:1033255583
Name:SOUTHWAY INTERNISTS PLLC
Entity Type:Organization
Organization Name:SOUTHWAY INTERNISTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-743-5639
Mailing Address - Street 1:222 SOUTHWAY
Mailing Address - Street 2:SUITE #C
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2703
Mailing Address - Country:US
Mailing Address - Phone:208-746-1333
Mailing Address - Fax:208-746-8090
Practice Address - Street 1:222 SOUTHWAY
Practice Address - Street 2:SUITE C
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2703
Practice Address - Country:US
Practice Address - Phone:208-746-1333
Practice Address - Fax:208-746-8090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8667494301Medicare PIN
ID1374912Medicare ID - Type Unspecified
WAGAB13949Medicare PIN