Provider Demographics
NPI:1588714489
Name:COEUR D ALENE SPINE AND BRAIN PLLC
Entity type:Organization
Organization Name:COEUR D ALENE SPINE AND BRAIN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:TANSY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-765-9100
Mailing Address - Street 1:3320 N GRAND MILL LN
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-5689
Mailing Address - Country:US
Mailing Address - Phone:208-765-9100
Mailing Address - Fax:208-765-9103
Practice Address - Street 1:3320 N GRAND MILL LN
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-5689
Practice Address - Country:US
Practice Address - Phone:208-765-9100
Practice Address - Fax:208-765-9103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8677174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806619500Medicaid
8948154OtherCRIME VICTIMS COMP FUND
8H195OtherBLUE CROSS OF IDAHO
DA4210OtherMEDICARE RR
000010143406OtherREGENCE BLUESHIELD
0172116OtherWASHINGTON L & I
205112900OtherOWCP
WA7116981Medicaid
8948154OtherCRIME VICTIMS COMP FUND
000010143406OtherREGENCE BLUESHIELD