Provider Demographics
NPI:1053344085
Name:LAENNEC INPATIENT SERVICES
Entity type:Organization
Organization Name:LAENNEC INPATIENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENTOWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ISCOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-712-2403
Mailing Address - Street 1:1717 MAIN ST
Mailing Address - Street 2:SUITE 5200
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-4612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:415 6TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2431
Practice Address - Country:US
Practice Address - Phone:208-799-5522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8M857OtherBLUE CROSS
ID000010159968OtherBLUE SHIELD
WA7136468Medicaid
ID8M857OtherBLUE CROSS
WA7136468Medicaid
ID1369124Medicare PIN