Provider Demographics
NPI:1902802549
Name:WHITING, MICHAEL ANTHONY (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:WHITING
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:TONY
Other - Middle Name:
Other - Last Name:WHITING
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 609
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-0609
Mailing Address - Country:US
Mailing Address - Phone:208-664-1119
Mailing Address - Fax:208-765-4340
Practice Address - Street 1:850 W IRONWOOD DR
Practice Address - Street 2:STE 103
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4903
Practice Address - Country:US
Practice Address - Phone:208-664-1119
Practice Address - Fax:208-765-4340
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-19122251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807065400Medicaid
ID1655867Medicare ID - Type Unspecified