Provider Demographics
NPI:1629392154
Name:KOOTENAI URGENT CARE LLC
Entity Type:Organization
Organization Name:KOOTENAI URGENT CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:KOELSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-676-0145
Mailing Address - Street 1:700 W IRONWOOD DR
Mailing Address - Street 2:SUITE 272E
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2656
Mailing Address - Country:US
Mailing Address - Phone:208-676-0145
Mailing Address - Fax:208-676-0147
Practice Address - Street 1:1300 E MULLAN AVE
Practice Address - Street 2:SUITE 600
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-6052
Practice Address - Country:US
Practice Address - Phone:208-777-9110
Practice Address - Fax:208-777-1871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-26
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - 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
ID1369049OtherMEDICARE PART B PTAN
IDDQ3168OtherRAILROAD MEDICARE
ID1369049OtherMEDICARE PART B PTAN