Provider Demographics
NPI:1881100097
Name:NORTHWEST GASTROENTEROLOGY, PLLC
Entity type:Organization
Organization Name:NORTHWEST GASTROENTEROLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:ERIKA
Authorized Official - Last Name:CSANKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-505-3628
Mailing Address - Street 1:2156 EAGLECREST DR
Mailing Address - Street 2:
Mailing Address - City:FILER
Mailing Address - State:ID
Mailing Address - Zip Code:83328-5068
Mailing Address - Country:US
Mailing Address - Phone:503-505-3628
Mailing Address - Fax:
Practice Address - Street 1:526 SHOUP AVE W
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6050
Practice Address - Country:US
Practice Address - Phone:208-736-7620
Practice Address - Fax:855-830-4058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-26
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-11559207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty