1457424244 NPI number — MRS. CHARLENE PONTORIERO NP

Table of content: MRS. CHARLENE PONTORIERO NP (NPI 1457424244)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457424244 NPI number — MRS. CHARLENE PONTORIERO NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PONTORIERO
Provider First Name:
CHARLENE
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457424244
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
107 DILWORTH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLENDIVE
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59330-2053
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-345-8935
Provider Business Mailing Address Fax Number:
406-345-8908

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 DILWORTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENDIVE
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59330-2053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-345-8935
Provider Business Practice Location Address Fax Number:
406-345-8908
Provider Enumeration Date:
11/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  R30872 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 23960 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000063062 . This is a "BLUE CROSS OF MT" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 005027 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0720161 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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