1083727374 NPI number — BITTERROOT FAMILY MEDICINE, P.C.

Table of content: (NPI 1083727374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083727374 NPI number — BITTERROOT FAMILY MEDICINE, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BITTERROOT FAMILY MEDICINE, P.C.
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:
Provider Other Organization Name Type Code:
6
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:
1083727374
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 N 10TH ST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
HAMILTON
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59840-2319
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-363-3627
Provider Business Mailing Address Fax Number:
406-363-3638

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 N 10TH ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
HAMILTON
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59840-2319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-363-3627
Provider Business Practice Location Address Fax Number:
406-363-3638
Provider Enumeration Date:
08/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MYERS
Authorized Official First Name:
CRAIG
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
406-363-3627

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 27D1025693 . This is a "CLIA #" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 9970670 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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