Jon C Clyde, MD
Individual provider Active NPI Surgery Physician · Spokane, WA
NPI 1891767943 · NPPES record last updated Sep 8, 2016
Key facts
- NPI
- 1891767943
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Surgery Physician 208600000X
- License
- MD00027478 (WA)
- Practice address
- 217 W Cataldo Ave
Spokane, WA 99201-2217 - Phone
- (509) 747-6194
- Fax
- (509) 838-0824
- NPI assigned
- Feb 3, 2006
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 3
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in WA
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20041104000565 | WA | Practitioner - General Surgery | 6800783267 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| MD00027478 | WA | MD | Surgery Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Columbia Surgical Specialists, PS | Current |
Accepting new patients | |
| Columbia Surgical Specialists, PS | Surgery | Current |
Accepting new patients |
| Surgical Specialists of Spokane | Surgery | Past | Accepting new patients |
Locations
105 W 8th Ave
Ste 7010
Spokane, WA 99204
Phone (509) 353-3901
217 W Cataldo Ave
Spokane, WA 99201
Phone (509) 624-2326
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Surgery Physician | 208600000X | MD00027478 | WA | Yes |
Addresses
Primary practice location
217 W Cataldo Ave
Spokane, WA 99201-2217
Mailing address
PO Box 2242
Spokane, WA 99210-2242
Phone (509) 747-6194
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 305785 | Other | WA | LABOR& INDUSTRIES |
| P01152325 | Other | WA | RAILROAD MEDICARE |
| 1021532 | Medicaid | WA |
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All providers in Spokane, WA · Surgery Physician in Washington
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 8, 2016. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.