# COEUR D ALENE SPINE AND BRAIN PLLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1588714489
- **Authorized official:** LISA RAE TANSY (ADMINISTRATOR)
- **Authorized official phone:** (208) 765-9100

## Contact information

- **Practice address:** 3320 N GRAND MILL LN, COEUR D ALENE, ID 83814-5689
- **Practice address phone:** (208) 765-9100
- **Practice address fax:** (208) 765-9103
- **Mailing address:** 3320 N GRAND MILL LN, COEUR D ALENE, ID 83814-5689
- **Mailing address phone:** (208) 765-9100
- **Mailing address fax:** (208) 765-9103

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 174400000X | Specialist | M8677 | ID | Yes |

## Other

- **Enumeration date:** 01/11/2007
- **Last updated:** 02/23/2023

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 000010143406 | REGENCE BLUESHIELD | — |
| 01 | — | 0172116 | WASHINGTON L & I | — |
| 01 | — | 205112900 | OWCP | — |
| 05 | — | 7116981 | — | WA |
| 05 | — | 806619500 | — | ID |
| 01 | — | 8948154 | CRIME VICTIMS COMP FUND | — |
| 01 | — | 8H195 | BLUE CROSS OF IDAHO | — |
| 01 | — | DA4210 | MEDICARE RR | — |