Provider Demographics
NPI:1760435028
Name:MAINER, MICHAEL JACKS (MD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JACKS
Last Name:MAINER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3754 W INDIAN TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-4700
Mailing Address - Country:US
Mailing Address - Phone:509-328-7041
Mailing Address - Fax:509-328-7582
Practice Address - Street 1:3754 W INDIAN TRAIL RD
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-4700
Practice Address - Country:US
Practice Address - Phone:509-328-7041
Practice Address - Fax:509-328-7582
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00015454207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0195465OtherWORKERS' COMP
WA1105303Medicaid
WAP00209862OtherRAILROAD MEDICARE
WA8852844Medicare ID - Type Unspecified
F13839Medicare UPIN