Provider Demographics
NPI:1548299696
Name:PALOUSE MEDICAL PS
Entity type:Organization
Organization Name:PALOUSE MEDICAL PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:FOSBACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-332-2517
Mailing Address - Street 1:825 SE BISHOP BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-5537
Mailing Address - Country:US
Mailing Address - Phone:509-332-2517
Mailing Address - Fax:509-334-9247
Practice Address - Street 1:825 SE BISHOP BLVD STE 200
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-5537
Practice Address - Country:US
Practice Address - Phone:509-332-2517
Practice Address - Fax:509-334-9247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7085418Medicaid
ID003202800Medicaid
ID1376046Medicare ID - Type UnspecifiedMEDICARE OF IDAHO
WA7085418Medicaid
WA0411320001Medicare NSC