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General NPI Number Information
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NPI Number | 1538516471
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Entity Type | Individual
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Provider Name | ANTHONY CHRISTOPHER DERRICO D.O.
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Gender | Male
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Dates
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Enumeration Date | 05/20/2016
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Last Update Date | 04/24/2024
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Provider Practice Location Address
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Address Line | 2003 KOOTENAI HEALTH WAY
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City | COEUR D ALENE
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State | ID
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Zip | 83814-6051
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Country | US
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Telephone | 208-625-5700
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Fax | 208-625-5708
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Provider Business Mailing Address
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Address Line | 2003 KOOTENAI HEALTH WAY
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City | COEUR D ALENE
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State | ID
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Zip | 83814-6051
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Country | US
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Telephone | 208-625-5700
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Fax | 208-625-5708
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207PE0004X
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Taxonomy Name | Emergency Medical Services (Emergency Medicine) Physician
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License Number | TL-4136
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 207PE0004X
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Taxonomy Name | Emergency Medical Services (Emergency Medicine) Physician
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License Number | O-1453
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License Number State | ID
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Taxonomy #3
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 81336-021
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License Number State | WI
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