Provider Demographics
NPI:1255496980
Name:COEUR D'ALENE PEDIATRICS PA
Entity Type:Organization
Organization Name:COEUR D'ALENE PEDIATRICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:DEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BEREND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-667-0585
Mailing Address - Street 1:700 W IRONWOOD DR
Mailing Address - Street 2:SUITE 155
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2656
Mailing Address - Country:US
Mailing Address - Phone:208-667-0585
Mailing Address - Fax:208-667-0876
Practice Address - Street 1:700 W IRONWOOD DR
Practice Address - Street 2:SUITE 155
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2656
Practice Address - Country:US
Practice Address - Phone:208-667-0585
Practice Address - Fax:208-667-0876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID81869OtherBLUE CROSS
ID002584600Medicaid
ID8A976OtherBLUE CROSS OF IDAHO
ID000010006210OtherREGENCE BLUE SHIELD
ID002585300Medicaid
WA7092836Medicaid
ID1376829Medicare PIN
ID1376828Medicare PIN