Provider Demographics
NPI:1043396054
Name:ELKHORN MOUNTAIN HEALTH SERVICES INC
Entity Type:Organization
Organization Name:ELKHORN MOUNTAIN HEALTH SERVICES INC
Other - Org Name:BOULDER MEDICAL CLINIC INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:S
Authorized Official - Last Name:SWANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-225-4201
Mailing Address - Street 1:214 SOUTH MAIN
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:MT
Mailing Address - Zip Code:59632-0028
Mailing Address - Country:US
Mailing Address - Phone:406-225-4201
Mailing Address - Fax:406-225-9161
Practice Address - Street 1:214 SOUTH MAIN
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:MT
Practice Address - Zip Code:59632
Practice Address - Country:US
Practice Address - Phone:406-225-4201
Practice Address - Fax:406-225-9161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT720291Medicaid
000008284Medicare PIN
MT273817Medicare Oscar/Certification