Provider Demographics
NPI:1790876571
Name:SPOKANE FOOT AND ANKLE SURGERY CENTER
Entity Type:Organization
Organization Name:SPOKANE FOOT AND ANKLE SURGERY CENTER
Other - Org Name:COEUR D ALENE FOOT AND ANKLE SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:ISHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:208-666-0605
Mailing Address - Street 1:101 W IRONWOOD DR
Mailing Address - Street 2:STE 131
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-1404
Mailing Address - Country:US
Mailing Address - Phone:208-666-0605
Mailing Address - Fax:208-666-0916
Practice Address - Street 1:101 W IRONWOOD DR
Practice Address - Street 2:STE 131
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-1404
Practice Address - Country:US
Practice Address - Phone:208-666-0605
Practice Address - Fax:208-666-0916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID00329760Medicaid
ID00329760Medicaid
IDT02325Medicare UPIN