1043385248 NPI number — MARIANNE M. WILSON

Table of content: (NPI 1043385248)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043385248 NPI number — MARIANNE M. WILSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARIANNE M. WILSON
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GLACIER MEDICAL HOME HEALTH
Provider Other Organization Name Type Code:
3
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:
1043385248
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
802 2ND STREET SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CUT BANK
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59427
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-873-2236
Provider Business Mailing Address Fax Number:
406-873-2867

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
802 2ND STREET SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CUT BANK
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-873-2236
Provider Business Practice Location Address Fax Number:
406-873-2867
Provider Enumeration Date:
11/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
MARIANNE
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
OWNER DIRECTOR
Authorized Official Telephone Number:
406-873-2236

Provider Taxonomy Codes

  • Taxonomy code: 163WG0600X , with the licence number:  013820809 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163WH0200X , with the licence number: RN2262 , 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: 7914000 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 740747 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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