Provider Demographics
NPI:1316038904
Name:NORTH IDAHO MEDICAL CARE CENTERS PLLC
Entity Type:Organization
Organization Name:NORTH IDAHO MEDICAL CARE CENTERS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-666-2000
Mailing Address - Street 1:927 E POLSTON AVE
Mailing Address - Street 2:STE 303
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-9811
Mailing Address - Country:US
Mailing Address - Phone:208-664-3313
Mailing Address - Fax:
Practice Address - Street 1:1701 LINCOLN WAY
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2537
Practice Address - Country:US
Practice Address - Phone:208-667-9110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1112918OtherMEDICARE
ID002606200Medicaid
ID5297190003Medicare NSC
ID1112918Medicare PIN
ID1112918OtherMEDICARE
ID1112918Medicare UPIN
ID002606200Medicaid
ID5297190002Medicare NSC