Provider Demographics
NPI:1538144753
Name:INLAND NORTHWEST FOOT AND ANKLE PC
Entity Type:Organization
Organization Name:INLAND NORTHWEST FOOT AND ANKLE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:208-777-9794
Mailing Address - Street 1:1590 E POLSTON AVE
Mailing Address - Street 2:STE A
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5218
Mailing Address - Country:US
Mailing Address - Phone:208-777-9794
Mailing Address - Fax:208-777-9523
Practice Address - Street 1:1590 E POLSTON AVE
Practice Address - Street 2:STE A
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-5218
Practice Address - Country:US
Practice Address - Phone:208-777-9794
Practice Address - Fax:208-777-9523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-09
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP173213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDI0007985456OtherAETNA
IDP00224830OtherRR MEDICARE PIN
ID000010149213OtherBLUE SHIELD
IDP2165OtherBLUE CROSS - PROVIDER #
IDP9293OtherBLUE CROSS - CLINIC #
IDI0007985456OtherAETNA
IDP9293OtherBLUE CROSS - CLINIC #
ID1377961Medicare PIN