Provider Demographics
NPI:1740289024
Name:KOOTENAI OUTPATIENT SURGERY CNTR LLC
Entity type:Organization
Organization Name:KOOTENAI OUTPATIENT SURGERY CNTR LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:M
Authorized Official - Last Name:TORWIRT
Authorized Official - Suffix:
Authorized Official - Credentials:CASC
Authorized Official - Phone:208-625-6428
Mailing Address - Street 1:707 W IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2772
Mailing Address - Country:US
Mailing Address - Phone:208-625-6400
Mailing Address - Fax:208-625-6401
Practice Address - Street 1:707 W IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2772
Practice Address - Country:US
Practice Address - Phone:208-625-6400
Practice Address - Fax:208-625-6401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID307824261QA1903X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010029201OtherREGENCE BS
ID805910000Medicaid
ID04069OtherBCBS
ID13C0001037Medicare NSC
ID000010029201OtherREGENCE BS