Provider Demographics
NPI:1871033266
Name:CATALYST MEDICAL GROUP, PLLC
Entity Type:Organization
Organization Name:CATALYST MEDICAL GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KARL
Authorized Official - Middle Name:
Authorized Official - Last Name:SUNDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-746-1383
Mailing Address - Street 1:2315 8TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-7301
Mailing Address - Country:US
Mailing Address - Phone:208-746-1383
Mailing Address - Fax:208-746-6348
Practice Address - Street 1:2315 8TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501
Practice Address - Country:US
Practice Address - Phone:208-746-1383
Practice Address - Fax:208-746-6348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-03
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDBL17-000004332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1912458787Medicaid