Provider Demographics
NPI:1891834768
Name:NORTH IDAHO UROLOGY, PLLC
Entity Type:Organization
Organization Name:NORTH IDAHO UROLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:A
Authorized Official - Last Name:CHATFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-667-0621
Mailing Address - Street 1:980 W IRONWOOD DR
Mailing Address - Street 2:STE 104
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2668
Mailing Address - Country:US
Mailing Address - Phone:208-667-0621
Mailing Address - Fax:208-664-1709
Practice Address - Street 1:980 W IRONWOOD DR
Practice Address - Street 2:STE. 104
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2668
Practice Address - Country:US
Practice Address - Phone:208-667-0621
Practice Address - Fax:208-664-1709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-3632208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002667200Medicaid
ID002507200Medicaid
ID805898101Medicaid
ID1123697Medicare ID - Type UnspecifiedDR. RANDIL CLARK
ID1378100Medicare ID - Type UnspecifiedNORTH IDAHO UROLOGY
ID1144239Medicare ID - Type UnspecifiedDR. EDWARD ELLISON
ID805898101Medicaid