Provider Demographics
NPI:1104971365
Name:CHEWELAH ASSOCIATED PHYSICIANS PS
Entity type:Organization
Organization Name:CHEWELAH ASSOCIATED PHYSICIANS PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-935-8711
Mailing Address - Street 1:PO BOX 137
Mailing Address - Street 2:
Mailing Address - City:CHEWELAH
Mailing Address - State:WA
Mailing Address - Zip Code:99109-0137
Mailing Address - Country:US
Mailing Address - Phone:509-935-8711
Mailing Address - Fax:509-935-4882
Practice Address - Street 1:410 E KING ST
Practice Address - Street 2:
Practice Address - City:CHEWELAH
Practice Address - State:WA
Practice Address - Zip Code:99109-0137
Practice Address - Country:US
Practice Address - Phone:509-935-8711
Practice Address - Fax:509-935-4882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8901404OtherDEPT OF L&I
WA7123300Medicaid
WA7590946Medicaid
WA7109173Medicaid
CN7261OtherRAILROAD MEDICARE
WA7123300Medicaid
WA503868Medicare Oscar/Certification