Provider Demographics
NPI:1811214786
Name:BUCKALEW, NEILLY ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:NEILLY
Middle Name:ANN
Last Name:BUCKALEW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1869 E SELTICE WAY #531
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854
Mailing Address - Country:US
Mailing Address - Phone:507-284-2511
Mailing Address - Fax:
Practice Address - Street 1:3330 N GRAND MILL LN
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-5689
Practice Address - Country:US
Practice Address - Phone:208-777-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-30
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD455877208100000X
MN54367208100000X
MN105626208100000X
PAMT197074390200000X
ND15303208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN250000962Medicare PIN