Provider Demographics
NPI:1154328763
Name:NORTH IDAHO ENDOSCOPY CENTER PLLC
Entity Type:Organization
Organization Name:NORTH IDAHO ENDOSCOPY CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GAVIN
Authorized Official - Middle Name:S
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-665-9184
Mailing Address - Street 1:1607 LINCOLN WAY SUITE 100
Mailing Address - Street 2:
Mailing Address - City:COEURDALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2476
Mailing Address - Country:US
Mailing Address - Phone:208-665-9184
Mailing Address - Fax:208-665-7964
Practice Address - Street 1:1607 LINCOLN WAY SUITE 100
Practice Address - Street 2:
Practice Address - City:COEURDALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2476
Practice Address - Country:US
Practice Address - Phone:208-665-9184
Practice Address - Fax:208-665-7964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-29
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID04358OtherBLUE CROSS
ID000010138610OtherREGENCE BLUE SHIELD
ID490005464OtherRR MEDICARE
ID806363500Medicaid
ID23856OtherGROUP HEALTH
ID806363500Medicaid
ID1870473Medicare ID - Type Unspecified