Basic Information
| Provider Information | |||||||||
| NPI: | 1447546601 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TIPTON | ||||||||
| FirstName: | HALLIE | ||||||||
| MiddleName: | ANN KERINS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KERINS | ||||||||
| OtherFirstName: | HALLIE | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 30 MT HIGHWAY 91 S | ||||||||
| Address2: | |||||||||
| City: | DILLON | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597253535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4066831188 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 30 MT HIGHWAY 91 S | ||||||||
| Address2: | |||||||||
| City: | DILLON | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597253535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4066831188 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2011 | ||||||||
| LastUpdateDate: | 04/28/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 6086 | AK | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 33364 | MT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 33364 | 01 | MT | MT STATE BOARD OF MEDICAL EXAMINERS | OTHER | FT4695891 | 01 | MT | DEA | OTHER | MD9635 | 05 | AK | MEDICAID |