Provider Demographics
NPI:1114954179
Name:SANDPOINT PEDIATRICS LLP
Entity Type:Organization
Organization Name:SANDPOINT PEDIATRICS LLP
Other - Org Name:SANDPOINT PEDIATRICS IN BONNERS FERRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHELTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-265-2242
Mailing Address - Street 1:420 N 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1552
Mailing Address - Country:US
Mailing Address - Phone:208-265-2242
Mailing Address - Fax:208-265-8214
Practice Address - Street 1:420 N 2ND AVE
Practice Address - Street 2:100
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1552
Practice Address - Country:US
Practice Address - Phone:208-265-2242
Practice Address - Fax:208-265-8214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-49542080A0000X
IDM64472080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC-47894Medicare UPIN
IDQ-64384Medicare UPIN
IDC-36985Medicare UPIN
IDA-52555Medicare UPIN