Basic Information
| Provider Information | |||||||||
| NPI: | 1255386173 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEAK MEDICAL MONTANA OPERATIONS LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | WHITEFISH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1305 7TH ST | ||||||||
| Address2: | |||||||||
| City: | WHITEFISH | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599372850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4068623557 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1305 7TH ST | ||||||||
| Address2: | |||||||||
| City: | WHITEFISH | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599372850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4068623557 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 09/26/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BERG | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5054684752 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PEAK MEDICAL LLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 12679 | MT | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 314000000X | 12679 | MT | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 310233 | 05 | MT | MEDICAID | 3400878 | 05 | MT | MEDICAID | 0534480 | 05 | MT | MEDICAID | 3400867 | 05 | MT | MEDICAID |