Healthcare Provider Details

I. General information

NPI: 1811214786
Provider Name (Legal Business Name): NEILLY ANN BUCKALEW M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2010
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 N GRAND MILL LN
COEUR D ALENE ID
83814-5689
US

IV. Provider business mailing address

1869 E SELTICE WAY #531
POST FALLS ID
83854
US

V. Phone/Fax

Practice location:
  • Phone: 208-777-5511
  • Fax:
Mailing address:
  • Phone: 507-284-2511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT197074
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD455877
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number54367
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number105626
License Number StateMN
# 5
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number15303
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: