Provider Demographics
NPI:1467583153
Name:PAIN MANAGEMENT OF NORTH IDAHO, PLLC
Entity Type:Organization
Organization Name:PAIN MANAGEMENT OF NORTH IDAHO, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:KARL
Authorized Official - Last Name:MAGNUSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-664-2363
Mailing Address - Street 1:1686 W RIVERSTONE DR
Mailing Address - Street 2:STE 1
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-5779
Mailing Address - Country:US
Mailing Address - Phone:208-664-2363
Mailing Address - Fax:208-765-2903
Practice Address - Street 1:1686 W RIVERSTONE DR
Practice Address - Street 2:STE 1
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-5779
Practice Address - Country:US
Practice Address - Phone:208-664-2363
Practice Address - Fax:208-765-2903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7860208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1378137Medicare PIN
IDG52845Medicare UPIN