Provider Demographics
NPI:1053375105
Name:MACINERNEY, EDWARD J (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:J
Last Name:MACINERNEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-625-5250
Mailing Address - Fax:208-625-5251
Practice Address - Street 1:700 W IRONWOOD DR STE 320
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4485
Practice Address - Country:US
Practice Address - Phone:208-625-5250
Practice Address - Fax:208-625-5251
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-13060207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO060060916OtherRAILROAD MEDICARE
ID1053375105Medicaid
MO27025013OtherBCBS-KC
20007804OtherMEDICARE
ID1053375105Medicaid
20007804OtherMEDICARE