1790803765 NPI number — LOGAN HEALTH - CONRAD

Table of content: (NPI 1790803765)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790803765 NPI number — LOGAN HEALTH - CONRAD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOGAN HEALTH - CONRAD
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:
1790803765
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
805 SUNSET BLVD
Provider Second Line Business Mailing Address:
PO BOX 758
Provider Business Mailing Address City Name:
CONRAD
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59425-1717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-271-3211
Provider Business Mailing Address Fax Number:
406-271-3917

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 5TH AVE SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONRAD
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59425-2521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-271-3211
Provider Business Practice Location Address Fax Number:
406-271-3917
Provider Enumeration Date:
03/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NEWMILLER
Authorized Official First Name:
VICKI
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
406-434-3207

Provider Taxonomy Codes

  • Taxonomy code: 341600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000060712 . This is a "BCBS" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 0441285 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com