Basic Information
| Provider Information | |||||||||
| NPI: | 1275560617 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | POWELL COUNTY MEMORIAL HOSPITAL ASSOCIATION INC. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DEER LODGE MEDICAL CENTER - HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 HOLLENBACK LANE | ||||||||
| Address2: | |||||||||
| City: | DEER LODGE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597221828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4068462212 | ||||||||
| FaxNumber: | 4068463074 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 HOLLENBACK LANE | ||||||||
| Address2: | |||||||||
| City: | DEER LODGE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597221828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4068462212 | ||||||||
| FaxNumber: | 4068463074 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 03/01/2012 | ||||||||
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| AuthorizedOfficialLastName: | RICHARDS | ||||||||
| AuthorizedOfficialFirstName: | JAENA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4068467717 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 9623 | MT | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 282NC0060X | 10408 | MT | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 0411740 | 05 | MT | MEDICAID | 3100383 | 05 | MT | MEDICAID | 0311701 | 05 | MT | MEDICAID | 3503227 | 05 | MT | MEDICAID |