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Organization Active NPI

Chewelah Associated Physicians PS

  • Family Medicine Physician
  • Chewelah, WA
National Provider Identifier
1104971365
Registry record updated Jun 25, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
CHEWELAH ASSOCIATED PHYSICIANS PS
Practice address
410 E King St
Chewelah, WA 99109-0137
Phone
(509) 935-8711
Fax
(509) 935-4882
NPI assigned
Jan 25, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 25, 2009

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Thomas John Boone, MDNPI 1346325750
Title
Ceo
Phone
(509) 935-8711

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X Primary

Addresses

Primary practice location

410 E King St
Chewelah, WA 99109-0137

Mailing address

PO Box 137
Chewelah, WA 99109-0137
Phone (509) 935-8711

Other identifiers 5

IdentifierTypeStateIssuer
8901404OtherWADEPT OF L&I
7123300MedicaidWA
7590946MedicaidWA
7109173MedicaidWA
CN7261OtherRAILROAD MEDICARE

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040309000253 WA Part B Supplier - Clinic/Group Practice 9537057765 Receives reassigned benefits from 5 practitioners
Practice locations: Chewelah, WA
O20090513000593 WA Part A Provider - Rural Health Clinic 9537057765 Practice locations: Chewelah, WA

Rural health clinic certification: CCN 503868

Legal name
CHEWELAH ASSOCIATED PHYSICIANS PS
Doing business as
CHEWELAH ASSOCIATED PHYSICIANS
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Aug 31, 2001
Last certification
Aug 4, 2015
Ownership / control type
1B
Organization structure
CorporationProprietary
Incorporated
Oct 2, 1979 in WA
Enrollment address
410 E King St
Chewelah, WA 99109-0137

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 2

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Thomas J Boone Individual 5% Or Greater Direct Ownership Interest Oct 2, 1979 100%
Susan Boone Individual W-2 Managing EmployeeRN/ Manager/Adm Jun 22, 2015

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1169683200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1245888000000",
    "number": "1104971365",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 137",
            "city": "CHEWELAH",
            "state": "WA",
            "postal_code": "991090137",
            "telephone_number": "509-935-8711",
            "fax_number": "509-935-4882"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "410 E KING ST",
            "city": "CHEWELAH",
            "state": "WA",
            "postal_code": "991090137",
            "telephone_number": "509-935-8711",
            "fax_number": "509-935-4882"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHEWELAH ASSOCIATED PHYSICIANS PS",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-25",
        "last_updated": "2009-06-25",
        "status": "A",
        "authorized_official_last_name": "BOONE",
        "authorized_official_first_name": "THOMAS",
        "authorized_official_middle_name": "JOHN",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "509-935-8711",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DEPT OF L&I",
            "identifier": "8901404",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7123300",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7590946",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7109173",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "CN7261",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Chewelah, WA

Sources for this page

Verify at the official NPI Registry.