Basic Information
| Provider Information | |||||||||
| NPI: | 1104943489 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VERN H HORTON MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5750 COCHISE DRIVE | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598049746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062512160 | ||||||||
| FaxNumber: | 4062512160 | ||||||||
| Practice Location | |||||||||
| Address1: | 2827 FT MISSOULA RD | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067284100 | ||||||||
| FaxNumber: | 4063274502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2007 | ||||||||
| LastUpdateDate: | 01/07/2008 | ||||||||
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| AuthorizedOfficialLastName: | HORTON | ||||||||
| AuthorizedOfficialFirstName: | SUZANNE | ||||||||
| AuthorizedOfficialMiddleName: | BALL | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER CORP SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 4062512160 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 3719 | MT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0019617 | 05 | MT | MEDICAID |