Provider Demographics
NPI:1134219330
Name:NORTH IDAHO NEUROSURGERY AND SPINE, PLLC
Entity type:Organization
Organization Name:NORTH IDAHO NEUROSURGERY AND SPINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:208-777-7555
Mailing Address - Street 1:1641 E. POLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854
Mailing Address - Country:US
Mailing Address - Phone:208-777-7555
Mailing Address - Fax:208-777-3337
Practice Address - Street 1:1641 E. POLSTON AVE.
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854
Practice Address - Country:US
Practice Address - Phone:208-777-7555
Practice Address - Fax:208-777-3337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-7768204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806107400Medicaid
ID805400800Medicaid
ID1277650001Medicare NSC
ID1376455Medicare UPIN
ID1376455Medicare ID - Type UnspecifiedGROUP