Basic Information
| Provider Information | |||||||||
| NPI: | 1891159877 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | POWELL COUNTY MEMORIAL HOSPITAL ASSOCIATION INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DEER LODGE MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 HOLLENBACK LN. | ||||||||
| Address2: | |||||||||
| City: | DEER LODGE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4068462212 | ||||||||
| FaxNumber: | 4068462789 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 HOLLENBACK LN. | ||||||||
| Address2: | |||||||||
| City: | DEER LODGE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4068462212 | ||||||||
| FaxNumber: | 4068462789 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2016 | ||||||||
| LastUpdateDate: | 04/06/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RICHARDS | ||||||||
| AuthorizedOfficialFirstName: | JAENA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4068462212 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | POWELL COUNTY MEMORIAL HOSPITAL ASSOCIAT | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | MT | Y | Hospitals | General Acute Care Hospital | Critical Access |
No ID Information.