Basic Information
Provider Information | |||||||||
NPI: | 1710165105 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MISSOULA COMMUNITY HEALTH SERVICES, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TAMARACK MEDICAL CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 66 | ||||||||
Address2: |   | ||||||||
City: | SUPERIOR | ||||||||
State: | MT | ||||||||
PostalCode: | 598720066 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4068224278 | ||||||||
FaxNumber: | 4068224912 | ||||||||
Practice Location | |||||||||
Address1: | 1208 6TH AVE | ||||||||
Address2: |   | ||||||||
City: | SUPERIOR | ||||||||
State: | MT | ||||||||
PostalCode: | 598729618 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4068224278 | ||||||||
FaxNumber: | 4068224912 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/07/2008 | ||||||||
LastUpdateDate: | 04/05/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCNEECE | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 4068224841 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |   |
No ID Information.