Provider Demographics
NPI:1639116452
Name:SPOKANE CARDIOLOGY PS
Entity Type:Organization
Organization Name:SPOKANE CARDIOLOGY PS
Other - Org Name:KOOTENAI HEART AND VASCULAR HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-455-8820
Mailing Address - Street 1:910 W 5TH AVE
Mailing Address - Street 2:300
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2966
Mailing Address - Country:US
Mailing Address - Phone:509-455-8820
Mailing Address - Fax:509-838-4978
Practice Address - Street 1:910 W 5TH AVE
Practice Address - Street 2:300
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2966
Practice Address - Country:US
Practice Address - Phone:509-455-8820
Practice Address - Fax:509-838-4978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7826803Medicaid
WA11246OtherL & I
WA11246OtherL & I
WAGAB36870Medicare UPIN