Provider Demographics
NPI:1063632388
Name:CHEWELAH ASSOCIATED PHYSICIANS
Entity Type:Organization
Organization Name:CHEWELAH ASSOCIATED PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-935-8711
Mailing Address - Street 1:410 E KING ST
Mailing Address - Street 2:
Mailing Address - City:CHEWELAH
Mailing Address - State:WA
Mailing Address - Zip Code:99109
Mailing Address - Country:US
Mailing Address - Phone:509-935-8711
Mailing Address - Fax:509-935-4882
Practice Address - Street 1:410 E KING ST
Practice Address - Street 2:
Practice Address - City:CHEWELAH
Practice Address - State:WA
Practice Address - Zip Code:99109
Practice Address - Country:US
Practice Address - Phone:509-935-8711
Practice Address - Fax:509-935-4882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-27
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7109176Medicaid