Basic Information
| Provider Information | |||||||||
| NPI: | 1336115849 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LOGAN HEALTH - WHITEFISH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EUREKA HEALTHCARE PRIMARY CARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 304 OSLOSKI RD | ||||||||
| Address2: | PO BOX 810 | ||||||||
| City: | EUREKA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599179217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062973145 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 304 OSLOSKI RD | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062973145 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 12/16/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ABEL | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4068633500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QR1300X | 12588 | MT | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 000081879 | 01 | MT | MEDICARE PART B | OTHER |