Provider Demographics
NPI:1669789228
Name:NORTHWEST SPINE AND PAIN MEDICINE, PLLC
Entity type:Organization
Organization Name:NORTHWEST SPINE AND PAIN MEDICINE, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-464-6208
Mailing Address - Street 1:PO BOX 112
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99210-0112
Mailing Address - Country:US
Mailing Address - Phone:509-464-6208
Mailing Address - Fax:888-316-1928
Practice Address - Street 1:3124 S REGAL ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-4704
Practice Address - Country:US
Practice Address - Phone:509-464-6208
Practice Address - Fax:888-316-1928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-02
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1300X, 103TC0700X
WAMD00048246261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2607164OtherCIGNA
WAG8896124Medicare UPIN