Provider Demographics
NPI:1215936638
Name:NORTH IDAHO DERMATOLOGY, P.A.
Entity type:Organization
Organization Name:NORTH IDAHO DERMATOLOGY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:CRAIG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-665-7546
Mailing Address - Street 1:2199 N MERRITT CREEK LOOP
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4949
Mailing Address - Country:US
Mailing Address - Phone:208-665-7546
Mailing Address - Fax:208-667-4607
Practice Address - Street 1:2199 N MERRITT CREEK LOOP
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4949
Practice Address - Country:US
Practice Address - Phone:208-665-7546
Practice Address - Fax:208-667-4607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-18
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003663100Medicaid
ID805487300Medicaid
ID805947800Medicaid
ID806523200Medicaid
ID003663100Medicaid
ID1102008Medicare ID - Type UnspecifiedDOMINEY
IDE55980Medicare UPIN
ID1666864Medicare ID - Type UnspecifiedFLYGARE
ID1344091Medicare ID - Type UnspecifiedARMSTRONG
ID806523200Medicaid
ID805487300Medicaid
IDF43728Medicare UPIN
ID1141974Medicare ID - Type UnspecifiedCRAIG