Provider Demographics
NPI:1679730436
Name:PROVIDENCE HEALTH & SERVICES MT
Entity type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES MT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RCM OPERATIONS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERI
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-329-5795
Mailing Address - Street 1:PO BOX 12
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0012
Mailing Address - Country:US
Mailing Address - Phone:406-329-5615
Mailing Address - Fax:406-329-5606
Practice Address - Street 1:1417 9TH ST S
Practice Address - Street 2:SUITE 203
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-4509
Practice Address - Country:US
Practice Address - Phone:406-771-7700
Practice Address - Fax:406-329-5606
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH & SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-20
Last Update Date:2013-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTM000009936Medicare PIN