Provider Demographics
NPI:1407335367
Name:BEACON CANCER CARE PLLC
Entity Type:Organization
Organization Name:BEACON CANCER CARE PLLC
Other - Org Name:BEACON CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:CADWELL
Authorized Official - Last Name:BARTELS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-775-2804
Mailing Address - Street 1:3815 N SCHREIBER WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-8362
Mailing Address - Country:US
Mailing Address - Phone:208-755-2804
Mailing Address - Fax:208-765-0277
Practice Address - Street 1:3815 N SCHREIBER WAY STE 101
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8362
Practice Address - Country:US
Practice Address - Phone:208-755-2804
Practice Address - Fax:208-765-0277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-11
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematologyGroup - Multi-Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
No261QX0200XAmbulatory Health Care FacilitiesClinic/CenterOncology
No261QX0203XAmbulatory Health Care FacilitiesClinic/CenterOncology, RadiationGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1407335367Medicaid
WA2107483Medicaid