Healthcare Provider Details

I. General information

NPI: 1336194703
Provider Name (Legal Business Name): NW CARDIOTHORACIC & TRANSPLANT SURGEONS P.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 07/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W 8TH AVE SUITE 532
SPOKANE WA
99204-2307
US

IV. Provider business mailing address

105 W 8TH AVE SUITE 532
SPOKANE WA
99204-2307
US

V. Phone/Fax

Practice location:
  • Phone: 509-623-7575
  • Fax: 509-623-7578
Mailing address:
  • Phone: 509-623-7575
  • Fax: 509-623-7578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. TIMOTHY B ICENOGLE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 509-623-7575