1811918998 NPI number — TOBACCO ROOT ANESTHESIOLOGY, LLC

Table of content: (NPI 1811918998)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811918998 NPI number — TOBACCO ROOT ANESTHESIOLOGY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TOBACCO ROOT ANESTHESIOLOGY, LLC
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:
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:
1811918998
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1330
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THREE FORKS
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59752-1330
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-285-6588
Provider Business Mailing Address Fax Number:
406-285-9012

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7 VANDOLAH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THREE FORKS
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59752-8673
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-285-6588
Provider Business Practice Location Address Fax Number:
406-285-9012
Provider Enumeration Date:
07/22/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
VANDOLAH
Authorized Official First Name:
MARK
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
406-285-6588

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  RN14372 , 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: 4308525 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".