Healthcare Provider Details

I. General information

NPI: 1851799621
Provider Name (Legal Business Name): ORTHOPEDIC SPECIALTY INSTITUTE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2014
Last Update Date: 11/01/2023
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1621 N 3RD ST STE 100
COEUR D ALENE ID
83814-3384
US

IV. Provider business mailing address

1621 N 3RD ST STE 100
COEUR D ALENE ID
83814-3384
US

V. Phone/Fax

Practice location:
  • Phone: 208-758-0716
  • Fax: 208-667-7717
Mailing address:
  • Phone: 208-758-0716
  • Fax: 208-667-7717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: CAITLIN A ST MARK
Title or Position: PRACTICE MANAGER
Credential:
Phone: 208-758-0486