Provider Demographics
NPI:1336194703
Name:NW CARDIOTHORACIC & TRANSPLANT SURGEONS P.S.
Entity Type:Organization
Organization Name:NW CARDIOTHORACIC & TRANSPLANT SURGEONS P.S.
Other - Org Name:NORTHWEST CARDIOTHORACIC & TRANSPLANT SURGEONS, PS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:B
Authorized Official - Last Name:ICENOGLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-623-7575
Mailing Address - Street 1:105 W 8TH AVE
Mailing Address - Street 2:SUITE 532
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2307
Mailing Address - Country:US
Mailing Address - Phone:509-623-7575
Mailing Address - Fax:509-623-7578
Practice Address - Street 1:105 W 8TH AVE
Practice Address - Street 2:SUITE 532
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2307
Practice Address - Country:US
Practice Address - Phone:509-623-7575
Practice Address - Fax:509-623-7578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204F00000XAllopathic & Osteopathic PhysiciansTransplant SurgeryGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA601433334OtherSTATE LICENSE UBI
WA30277OtherL&I LICENSE NUMBER
WAG000302400Medicare PIN