Provider Demographics
NPI:1407056237
Name:CANFIELD FAMILY MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:CANFIELD FAMILY MEDICAL GROUP LLC
Other - Org Name:CANFIELD FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:ADELE
Authorized Official - Last Name:LINDSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-765-4808
Mailing Address - Street 1:700 W IRONWOOD DR
Mailing Address - Street 2:SUITE 234
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2656
Mailing Address - Country:US
Mailing Address - Phone:208-765-4808
Mailing Address - Fax:208-676-9824
Practice Address - Street 1:700 W IRONWOOD DR
Practice Address - Street 2:SUITE 234
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2656
Practice Address - Country:US
Practice Address - Phone:208-765-4808
Practice Address - Fax:208-676-9824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8963174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDE07503Medicare UPIN
ID1131561Medicare PIN