Provider Demographics
NPI:1083949374
Name:OPPORTUNITY MEDICAL
Entity Type:Organization
Organization Name:OPPORTUNITY MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:L
Authorized Official - Last Name:GOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-926-1770
Mailing Address - Street 1:16201 E INDIANA AVE
Mailing Address - Street 2:STE. 2300
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99216-2839
Mailing Address - Country:US
Mailing Address - Phone:509-924-8721
Mailing Address - Fax:509-927-9593
Practice Address - Street 1:16201 E. INDIANA AVE
Practice Address - Street 2:STE 2300
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99216-2839
Practice Address - Country:US
Practice Address - Phone:509-924-8721
Practice Address - Fax:509-927-9593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-05
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602935992207Q00000X
WAMD00029097207Q00000X
WAOP00001703207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7119845Medicaid
WAG8885688Medicare PIN