Basic Information
| Provider Information | |||||||||
| NPI: | 1710901194 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PONDERA MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PONDERA MEDICAL CENTER REFERRAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P O BOX 758 | ||||||||
| Address2: | |||||||||
| City: | CONRAD | ||||||||
| State: | MT | ||||||||
| PostalCode: | 594250758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062713211 | ||||||||
| FaxNumber: | 4062717661 | ||||||||
| Practice Location | |||||||||
| Address1: | 805 SUNSET BLVD | ||||||||
| Address2: | |||||||||
| City: | CONRAD | ||||||||
| State: | MT | ||||||||
| PostalCode: | 594251717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062713211 | ||||||||
| FaxNumber: | 4062717661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 12/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4062713211 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | 10678 | MT | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.