Basic Information
| Provider Information | |||||||||
| NPI: | 1477862522 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARCUS DALY MEMORIAL HOSPITAL CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | RAVALLI UROLOGY | ||||||||
| 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: | 1224 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598402338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063754888 | ||||||||
| FaxNumber: | 4063754867 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2010 | ||||||||
| LastUpdateDate: | 11/29/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ERDMAN | ||||||||
| AuthorizedOfficialFirstName: | DONJA | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4063632211 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | N | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty | 208800000X | MT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 1477862522 | 05 | ID | MEDICAID | 1477862522 | 05 | MT | MEDICAID |