Provider Demographics
NPI:1942277710
Name:COEUR D ALENE PHYSICAL THERAPY AND SPORTS MEDICINE PA
Entity Type:Organization
Organization Name:COEUR D ALENE PHYSICAL THERAPY AND SPORTS MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:F
Authorized Official - Last Name:BARTOO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:208-667-3583
Mailing Address - Street 1:1917 N LAKEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2634
Mailing Address - Country:US
Mailing Address - Phone:208-667-3583
Mailing Address - Fax:208-667-2643
Practice Address - Street 1:1917 N LAKEWOOD DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2634
Practice Address - Country:US
Practice Address - Phone:208-667-3583
Practice Address - Fax:208-667-2643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-01
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDT0726OtherBLUE CROSS OF IDAHO
ID000010006968OtherREGENCE BLUE SHIELD OF ID
ID002711200Medicaid
1653128Medicare ID - Type Unspecified