1326058207 NPI number — STATE OF MONTANA

Table of content: (NPI 1326058207)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326058207 NPI number — STATE OF MONTANA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE OF MONTANA
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:
1326058207
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 N SANDERS ST RM 105
Provider Second Line Business Mailing Address:
P O BOX 6429
Provider Business Mailing Address City Name:
HELENA
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59601-4520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-444-4497
Provider Business Mailing Address Fax Number:
406-444-3082

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 FOURTH AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOULDER
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59632-0087
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-225-4410
Provider Business Practice Location Address Fax Number:
406-225-4414
Provider Enumeration Date:
08/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EVERETT
Authorized Official First Name:
TEDDI
Authorized Official Middle Name:
Authorized Official Title or Position:
FISCAL MANAGER
Authorized Official Telephone Number:
406-444-4497

Provider Taxonomy Codes

  • Taxonomy code: 315P00000X , with the licence number:  10867 , 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: 57-0037 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 57-0063 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 57-0336 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 57-2598 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 57-0095 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 57-0061 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 57-0050 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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