Provider Demographics
NPI:1104824150
Name:BURNETT, ROBERT J (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:BURNETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 W 7TH AVE
Mailing Address - Street 2:STE 110
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2349
Mailing Address - Country:US
Mailing Address - Phone:509-456-0262
Mailing Address - Fax:509-462-5059
Practice Address - Street 1:2003 KOOTENAI HEALTH WAY
Practice Address - Street 2:STE 300
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-6051
Practice Address - Country:US
Practice Address - Phone:208-666-2552
Practice Address - Fax:208-666-2556
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036338208G00000X
IDM-8773208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8878163OtherMEDICARE PTAN
WA8357345Medicaid
WAG8870910OtherMEDICARE PTAN
ID806593702Medicaid
ID11104691OtherMEDICARE PTAN
WA8357345Medicaid
WAG8870910OtherMEDICARE PTAN
ID1110469Medicare PIN