Provider Demographics
NPI:1023780376
Name:NORTHWEST PHYSICIANS AND SURGEONS
Entity type:Organization
Organization Name:NORTHWEST PHYSICIANS AND SURGEONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:CORY
Authorized Official - Middle Name:AVERILL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:208-667-9762
Mailing Address - Street 1:850 W IRONWOOD DR STE 301
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4903
Mailing Address - Country:US
Mailing Address - Phone:208-667-9762
Mailing Address - Fax:208-765-1041
Practice Address - Street 1:850 W IRONWOOD DR STE 301
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4903
Practice Address - Country:US
Practice Address - Phone:208-667-9762
Practice Address - Fax:208-765-1041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-04
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty