Basic Information
| Provider Information | |||||||||
| NPI: | 1952312050 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. JOHN'S LUTHERAN HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CABINET PEAKS MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 209 HEALTH PARK DR | ||||||||
| Address2: | PO BOX 1570 | ||||||||
| 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: | 08/11/2006 | ||||||||
| LastUpdateDate: | 09/20/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BURKE | ||||||||
| AuthorizedOfficialFirstName: | BRIGID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4062837219 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 282NC0060X | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 60672 | 01 | MT | BLUE CROSS PROVIDER | OTHER | 0412420 | 05 | MT | MEDICAID |