Provider Demographics
NPI:1093796468
Name:COEUR D' ALENE ANESTHESIA
Entity Type:Organization
Organization Name:COEUR D' ALENE ANESTHESIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:ROCK
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:208-262-2314
Mailing Address - Street 1:1593 E POLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5326
Mailing Address - Country:US
Mailing Address - Phone:208-262-2314
Mailing Address - Fax:208-262-2394
Practice Address - Street 1:1593 E POLSTON AVE
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-5326
Practice Address - Country:US
Practice Address - Phone:208-262-2314
Practice Address - Fax:208-262-2394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1602773Medicare ID - Type Unspecified