1518124379 NPI number — PROVIDENCE HEALTH & SERVICES MT

Table of content: (NPI 1518124379)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518124379 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 ANACONDA
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:
1518124379
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 12
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIBERTY LAKE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99019-0012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-747-2455
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1102 E COMMERCIAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANACONDA
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59711-2718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-329-5615
Provider Business Practice Location Address Fax Number:
406-563-8601
Provider Enumeration Date:
05/20/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
ASST SEC ENROLLMENT/DIR REIMB ADMIN
Authorized Official Telephone Number:
425-525-5392

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RI0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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