Basic Information
| Provider Information | |||||||||
| NPI: | 1487082087 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MONTANA SKIN CANCER AND DERMATOLOGY CENTER, P.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SKINCARE MT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1905 W COLLEGE ST | ||||||||
| Address2: | |||||||||
| City: | BOZEMAN | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597184061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065874432 | ||||||||
| FaxNumber: | 4065877015 | ||||||||
| Practice Location | |||||||||
| Address1: | 1905 W COLLEGE ST | ||||||||
| Address2: | |||||||||
| City: | BOZEMAN | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597184061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065874432 | ||||||||
| FaxNumber: | 4065877015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2013 | ||||||||
| LastUpdateDate: | 07/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | PETERSON | ||||||||
| AuthorizedOfficialFirstName: | DOE | ||||||||
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| AuthorizedOfficialTitleorPosition: | FINANCIAL ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4062060279 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 20664 | MT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.