Basic Information
| Provider Information | |||||||||
| NPI: | 1699872010 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUZANNE C GULLOTTA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAKESIDE FAMILY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 649 | ||||||||
| Address2: | |||||||||
| City: | LAKESIDE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599220649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4068572997 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 77 DEER CREEK ROAD | ||||||||
| Address2: | |||||||||
| City: | SOMERS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4068572997 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 01/18/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GULLOTTA | ||||||||
| AuthorizedOfficialFirstName: | SUZANNE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4068572997 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | NP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 020838 | MT | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 037108 | 01 | MT | BCBS | OTHER | 0434707 | 05 | MT | MEDICAID |