Physician Compare National (NPI:1285623819)

HEALTHCARE PROVIDER: CARL RAY DETTWILER MD

Physician Compare National contains general information about individual eligible professionals (EPs) such as demographic information and Medicare quality program participation.

Individual Professional Information
NPI	1285623819
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	2769457852
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20040907000488
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	DETTWILER
	Individual professional last name
Provider First Name	CARL
	Individual professional first name
Provider Middle Name	R
	Individual professional middle name
Provider Gender	M
	The provider's gender if the provider is a person.
Provider Credential Text	MD
	The abbreviations for professional degrees or credentials used or held by the provider, if the provider is an individual. Examples are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations will not be verified by NPS.

Medical School Information
Medical School Name	LOMA LINDA UNIVERSITY SCHOOL OF MEDICINE
	Individual professional's medical school
Graduation Year	1981
	Individual professional's medical school graduation year
Primary Specialty	GASTROENTEROLOGY
	Primary medical specialty reported by the individual professional in the selected enrollment

Practice Information
Line 1 Street Address	2517 17TH ST B
	Group Practice or individual's line 1 address
City	LEWISTON
	Group Practice or individual's city
State	ID
	Group Practice or individual's state
Zip Code	835016311
	Group Practice or individual's zip code (9 digits when available)

Hospital(s) Affiliation Information
Hospital Affiliation CCN 1	501332
	Medicare CCN of hospital where individual professional provides service 1
Hospital Affiliation LBN 1	TRI-STATE MEMORIAL HOSPITAL
	Legal business name of hospital where individual professional provides service 1
Hospital Affiliation CCN 2	130003
	Medicare CCN of hospital where individual professional provides service 2
Hospital Affiliation LBN 2	ST JOSEPH REGIONAL MEDICAL CENTER
	Legal business name of hospital where individual professional provides service 2
Hospital Affiliation CCN 3	131321
	Medicare CCN of hospital where individual professional provides service 3
Hospital Affiliation LBN 3	ST MARYS HOSPITAL AND CLINICS
	Legal business name of hospital where individual professional provides service 3
Hospital Affiliation CCN 4	131320
	Medicare CCN of hospital where individual professional provides service 4
Hospital Affiliation LBN 4	CLEARWATER VALLEY HOSPITAL & CLINICS
	Legal business name of hospital where individual professional provides service 4
Hospital Affiliation CCN 5	131315
	Medicare CCN of hospital where individual professional provides service 5
Hospital Affiliation LBN 5	SYRINGA GENERAL HOSPITAL
	Legal business name of hospital where individual professional provides service 5
Professional Accepts Medicare Assignment	Y

Physician Compare National (NPI:1285623819)

HEALTHCARE PROVIDER: CARL RAY DETTWILER MD

Individual Professional Information

Medical School Information

Practice Information

Hospital(s) Affiliation Information