Healthcare Provider Details

I. General information

NPI: 1407335367
Provider Name (Legal Business Name): BEACON CANCER CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2018
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3815 N SCHREIBER WAY STE 101
COEUR D ALENE ID
83815-8362
US

IV. Provider business mailing address

3815 N SCHREIBER WAY STE 101
COEUR D ALENE ID
83815-8362
US

V. Phone/Fax

Practice location:
  • Phone: 208-755-2804
  • Fax: 208-765-0277
Mailing address:
  • Phone: 208-755-2804
  • Fax: 208-765-0277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QX0200X
TaxonomyOncology Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QX0203X
TaxonomyRadiation Oncology Clinic/Center
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 10
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID CADWELL BARTELS
Title or Position: OWNER
Credential: DO
Phone: 208-775-2804