1235238718 NPI number — BUTTE SILVER BOW PRIMARY HEALTH CARE CLINIC INC

Table of content: (NPI 1235238718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235238718 NPI number — BUTTE SILVER BOW PRIMARY HEALTH CARE CLINIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BUTTE SILVER BOW PRIMARY HEALTH CARE CLINIC INC
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:
BLACKTAIL DENTAL
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:
1235238718
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
445 CENTENNIAL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BUTTE
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59701-2870
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-723-4075
Provider Business Mailing Address Fax Number:
406-496-6035

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 E GLENDALE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DILLON
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59725-2505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-683-4440
Provider Business Practice Location Address Fax Number:
406-683-1121
Provider Enumeration Date:
09/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MATICH
Authorized Official First Name:
BREANNA
Authorized Official Middle Name:
BETH
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
406-496-6000

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X , 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: 95601016 . This is a "MT BREAST & CERVICAL PROG" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 63392 . This is a "BCBS" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: CK5130 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 0730028 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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