Healthcare Provider Details

I. General information

NPI: 1538516471
Provider Name (Legal Business Name): ANTHONY CHRISTOPHER DERRICO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2016
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2003 KOOTENAI HEALTH WAY
COEUR D ALENE ID
83814-6051
US

IV. Provider business mailing address

2003 KOOTENAI HEALTH WAY
COEUR D ALENE ID
83814-6051
US

V. Phone/Fax

Practice location:
  • Phone: 208-625-5700
  • Fax: 208-625-5708
Mailing address:
  • Phone: 208-625-5700
  • Fax: 208-625-5708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number81336-021
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberTL-4136
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberO-1453
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: