Organization
KOOTENAI URGENT CARE LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ERIC KOELSCH (EXECUTIVE DIRECTOR)
(208) 676-0145
Entity
Organization
Contact information
Practice address
566 W PRAIRIE AVE, COEUR D ALENE, ID 83815-7766
(208) 772-9110
(208) 772-0590
Mailing address
700 W IRONWOOD DR, SUITE 272E, COEUR D ALENE, ID 83814-2656
(208) 676-0102
(208) 676-0147
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
363A00000X
Physician Assistant
—
—
363L00000X
Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1369049
MEDICARE PART B PTAN
ID
01
—
DQ3168
RAILROAD MEDICARE
ID
Enumeration date
04/07/2010
Last updated
03/22/2012
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