1275789901 NPI number — GLACIER ONCOLOGY, PLLC

Table of content: (NPI 1275789901)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275789901 NPI number — GLACIER ONCOLOGY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLACIER ONCOLOGY, PLLC
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:
1275789901
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
75 CLAREMONT ST
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
KALISPELL
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59901-3585
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-752-7600
Provider Business Mailing Address Fax Number:
406-752-7614

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 CLAREMONT ST
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
KALISPELL
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59901-3585
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-752-7600
Provider Business Practice Location Address Fax Number:
406-752-7614
Provider Enumeration Date:
08/13/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GOODMAN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
G
Authorized Official Title or Position:
SOLE PROPRIETOR
Authorized Official Telephone Number:
406-752-7600

Provider Taxonomy Codes

  • Taxonomy code: 261QX0200X , with the licence number:  8025 , 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: 830004450 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 011071 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 0105825 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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