Provider Demographics
NPI:1629291273
Name:NORTHWEST RENAL SERVICES INC
Entity Type:Organization
Organization Name:NORTHWEST RENAL SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEO
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:OBERMILLER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:509-744-1500
Mailing Address - Street 1:801 W 5TH AVE
Mailing Address - Street 2:SUITE #323
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2823
Mailing Address - Country:US
Mailing Address - Phone:509-744-1500
Mailing Address - Fax:509-626-5460
Practice Address - Street 1:801 W 5TH AVE
Practice Address - Street 2:SUITE #323
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2823
Practice Address - Country:US
Practice Address - Phone:509-744-1500
Practice Address - Fax:509-626-5460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601983029207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
010100010060OtherREGENCE BLUE SHIELD OF ID
WA7098122Medicaid
CK4277Medicare PIN
AB12473Medicare PIN
1374533Medicare PIN