Basic Information
| Provider Information | |||||||||
| NPI: | 1336213446 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST LUKES COMMUNITY HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 107 6TH AVE SW | ||||||||
| Address2: | |||||||||
| City: | RONAN | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598642634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4066764441 | ||||||||
| FaxNumber: | 4066760835 | ||||||||
| Practice Location | |||||||||
| Address1: | 107 6TH AVE SW | ||||||||
| Address2: | |||||||||
| City: | RONAN | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598642634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4066764441 | ||||||||
| FaxNumber: | 4066760835 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 11/05/2012 | ||||||||
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| AuthorizedOfficialLastName: | ROBERTS | ||||||||
| AuthorizedOfficialFirstName: | SHANE | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4066764441 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 10834 | MT | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 0412711 | 05 | MT | MEDICAID |