Healthcare Provider Details

I. General information

NPI: 1104824150
Provider Name (Legal Business Name): ROBERT J BURNETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2003 KOOTENAI HEALTH WAY STE 300
COEUR D ALENE ID
83814-6051
US

IV. Provider business mailing address

122 W 7TH AVE STE 110
SPOKANE WA
99204-2349
US

V. Phone/Fax

Practice location:
  • Phone: 208-666-2552
  • Fax: 208-666-2556
Mailing address:
  • Phone: 509-456-0262
  • Fax: 509-462-5059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberMD00036338
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberM-8773
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: