Basic Information
| Provider Information | |||||||||
| NPI: | 1053613356 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE HEALTH & SERVICES MT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PMG MT IHI STEVENSVILLE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34439 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981241439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063295615 | ||||||||
| FaxNumber: | 4063295606 | ||||||||
| Practice Location | |||||||||
| Address1: | 715 MAIN STREET | ||||||||
| Address2: | STE A | ||||||||
| City: | STEVENSVILLE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598702861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067775522 | ||||||||
| FaxNumber: | 4065417001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2010 | ||||||||
| LastUpdateDate: | 06/22/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MASTERS | ||||||||
| AuthorizedOfficialFirstName: | TERI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | RCM OPERATIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4063295795 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROVIDENCE HEALTH & SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
No ID Information.