Healthcare Provider Details

I. General information

NPI: 1629291273
Provider Name (Legal Business Name): NORTHWEST RENAL SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 01/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 W 5TH AVE SUITE #323
SPOKANE WA
99204-2823
US

IV. Provider business mailing address

801 W 5TH AVE SUITE #323
SPOKANE WA
99204-2823
US

V. Phone/Fax

Practice location:
  • Phone: 509-744-1500
  • Fax: 509-626-5460
Mailing address:
  • Phone: 509-744-1500
  • Fax: 509-626-5460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number601983029
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number601983029
License Number StateWA

VIII. Authorized Official

Name: DR. LEO EUGENE OBERMILLER JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 509-744-1500