1053613356 NPI number — PROVIDENCE HEALTH & SERVICES MT

Table of content: (NPI 1053613356)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053613356 NPI number — PROVIDENCE HEALTH & SERVICES MT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE HEALTH & SERVICES MT
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:
PMG MT IHI STEVENSVILLE
Provider Other Organization Name Type Code:
5
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:
1053613356
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 34439
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98124-1439
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-329-5615
Provider Business Mailing Address Fax Number:
406-329-5606

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
715 MAIN STREET
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
STEVENSVILLE
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59870-2861
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-777-5522
Provider Business Practice Location Address Fax Number:
406-541-7001
Provider Enumeration Date:
11/19/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MASTERS
Authorized Official First Name:
TERI
Authorized Official Middle Name:
Authorized Official Title or Position:
RCM OPERATIONS MANAGER
Authorized Official Telephone Number:
406-329-5795

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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