Provider Demographics
NPI:1902911878
Name:MEADOW, PHILIP BRUCE (DO FACR)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:BRUCE
Last Name:MEADOW
Suffix:
Gender:M
Credentials:DO FACR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-625-4000
Mailing Address - Fax:
Practice Address - Street 1:700 W IRONWOOD DR STE 275W
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4400
Practice Address - Country:US
Practice Address - Phone:208-625-4780
Practice Address - Fax:208-625-4781
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043709207RR0500X
IDO-1470207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA660003950OtherRAILROAD MEDICARE
GA66BBGBOtherMEDICARE ID
GA1437288255OtherMEDICARE GROUP NPI
GA000750373CMedicaid
GAGRP4761OtherMEDICARE GROUP PTAN
GA660003950OtherRAILROAD MEDICARE