Provider Demographics
NPI:1760816037
Name:NORTH IDAHO REHABILITATION MEDICINE, PLLC
Entity Type:Organization
Organization Name:NORTH IDAHO REHABILITATION MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:E
Authorized Official - Last Name:GROSSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-293-2276
Mailing Address - Street 1:2407 W RAINIER CT
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-9259
Mailing Address - Country:US
Mailing Address - Phone:509-293-2276
Mailing Address - Fax:818-889-0517
Practice Address - Street 1:600 N CECIL RD
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-6200
Practice Address - Country:US
Practice Address - Phone:509-293-2276
Practice Address - Fax:818-889-0517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-22
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-11628208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG26461Medicare UPIN