Provider Demographics
NPI:1134137599
Name:SPOKANE PLASTIC SURGEONS PS
Entity Type:Organization
Organization Name:SPOKANE PLASTIC SURGEONS PS
Other - Org Name:SPOKANE PLASTIC SURGEONS SURGICENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CROW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-484-1212
Mailing Address - Street 1:235 E ROWAN AVE
Mailing Address - Street 2:STE 206
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99207-1240
Mailing Address - Country:US
Mailing Address - Phone:509-484-1212
Mailing Address - Fax:509-484-1277
Practice Address - Street 1:235 E ROWAN AVE
Practice Address - Street 2:STE 206
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-1240
Practice Address - Country:US
Practice Address - Phone:509-484-1212
Practice Address - Fax:509-484-1277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA208200000X, 261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDK9751OtherBC-IDAHO MANAGED CARE GR#
WA555OtherGHC GROUP PROVIDER #
WA108585OtherL&I GROUP PROVIDER #
WA7091358Medicaid
CK7107Medicare PIN
WA555OtherGHC GROUP PROVIDER #