Basic Information
| Provider Information | |||||||||
| NPI: | 1033127659 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SURGICAL BARIATRICS NORTHWEST, INC. P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 750 N SYRINGA ST | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838545275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082620945 | ||||||||
| FaxNumber: | 2084150150 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 N SYRINGA ST | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838545275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082620945 | ||||||||
| FaxNumber: | 2084150150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 07/18/2007 | ||||||||
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| AuthorizedOfficialLastName: | PENNINGS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2082620945 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.