1043469513 NPI number — BENEFIS MEDICAL GROUP

Table of content: (NPI 1043469513)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043469513 NPI number — BENEFIS MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BENEFIS MEDICAL GROUP
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:
1043469513
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/22/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 6010
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREAT FALLS
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59406-6010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-455-2900
Provider Business Mailing Address Fax Number:
406-455-2902

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1117 29TH STREET SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREAT FALLS
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59405-5306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-455-8150
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/09/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SPEER
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
406-455-2920

Provider Taxonomy Codes

  • Taxonomy code: 2080P0207X , with the licence number:  10145 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X , with the licence number: 7270 , 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: 830006549 . This is a "RR" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 0000372861 . This is a "W-BCBS" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 500018658 . This is a "RR" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: P00386826 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: P00393761 . This is a "RR" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 0000093788 . This is a "H-BCBS" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 0000094908 . This is a "B-BCBS" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 0000099035 . This is a "BCBS" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".




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