Healthcare Provider Details

I. General information

NPI: 1114966769
Provider Name (Legal Business Name): NORTHSIDE INTERNAL MEDICINE ASSOCIATES PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 12/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6120 N MAYFAIR
SPOKANE WA
99208
US

IV. Provider business mailing address

6120 N MAYFAIR
SPOKANE WA
99208
US

V. Phone/Fax

Practice location:
  • Phone: 509-489-7483
  • Fax: 509-489-4572
Mailing address:
  • Phone: 509-489-7483
  • Fax: 509-489-4572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY J GARDNER
Title or Position: PRESIDENT
Credential: MD
Phone: 509-489-7483