Basic Information
| Provider Information | |||||||||
| NPI: | 1457656548 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARCUS DALY MEMORIAL HOSPITAL CORP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BITTERROOT HEALTH-ORTHOPEDICS AND SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1224 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598402338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063754823 | ||||||||
| FaxNumber: | 4063754846 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 WESTWOOD DR STE H | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598402345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063754868 | ||||||||
| FaxNumber: | 4063754655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2011 | ||||||||
| LastUpdateDate: | 09/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | BISHOP | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4063632211 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1457656548 | 05 | MT | MEDICAID | 1457656548 | 05 | ID | MEDICAID | 207X00000X | 01 | MT | TAXONOMY | OTHER |