MEDICARE: KOOTENAI URGENT CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	363A00000X	Physician Assistant
2	363L00000X	Nurse Practitioner
3	207Q00000X	Family Medicine Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1369049	OTHER	ID	MEDICARE PART B PTAN
2	DQ3168	OTHER	ID	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1407172059
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOOTENAI URGENT CARE LLC

Provider Business Mailing Address
First Line	:	700 W IRONWOOD DR
Second Line	:	SUITE 272E
City	:	COEUR D ALENE
State	:	ID
Zip	:	83814-2656
Country	:	US
Telephone Number	:	208-676-0102
Fax Number	:	208-676-0147

Provider Business Practice Location Address
First Line	:	566 W PRAIRIE AVE
Second Line	:
City	:	COEUR D ALENE
State	:	ID
Zip	:	83815-7766
Country	:	US
Telephone Number	:	208-772-9110
Fax Number	:	208-772-0590

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	ERIC KOELSCH
Credential	:
Telephone Number	:	208-676-0145

Provider Enumeration Date	:	04/07/2010
Last Update Date	:	03/22/2012

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