Provider Demographics
NPI:1952355539
Name:ST JOSEPHS EAR NOSE AND THROAT CLINIC PLLC
Entity Type:Organization
Organization Name:ST JOSEPHS EAR NOSE AND THROAT CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:DETAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACS
Authorized Official - Phone:208-777-1320
Mailing Address - Street 1:849 N SYRINGA ST
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-8794
Mailing Address - Country:US
Mailing Address - Phone:208-777-1320
Mailing Address - Fax:208-777-1322
Practice Address - Street 1:849 N SYRINGA ST
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-8794
Practice Address - Country:US
Practice Address - Phone:208-777-1320
Practice Address - Fax:208-777-1322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID151513OtherWASHINGTON L&I
ID0000100006619OtherREGENCE/ASURIS
ID7087273Medicaid
ID8938054OtherWA L&I CRIME VICTIMS
ID805084300Medicaid
ID8M012OtherBLUE CROSS OF IDAHO
ID805084300Medicaid
ID151513OtherWASHINGTON L&I