Basic Information
| Provider Information | |||||||||
| NPI: | 1588720882 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. JOHN'S LUTHERAN HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CABINET PEAKS MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 209 HEALTH PARK DR | ||||||||
| Address2: | |||||||||
| City: | LIBBY | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599232001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062837000 | ||||||||
| FaxNumber: | 4062933895 | ||||||||
| Practice Location | |||||||||
| Address1: | 209 HEALTH PARK DR | ||||||||
| Address2: | |||||||||
| City: | LIBBY | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599232001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062837000 | ||||||||
| FaxNumber: | 4062933895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2006 | ||||||||
| LastUpdateDate: | 06/22/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BURKE | ||||||||
| AuthorizedOfficialFirstName: | BRIGID | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4062837219 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 10828 | MT | N | Hospital Units | Medicare Defined Swing Bed Unit | 275N00000X | 11971 | MT | Y | Hospital Units | Medicare Defined Swing Bed Unit |
ID Information
| ID | Type | State | Issuer | Description | 3100006 | 05 | MT | MEDICAID |