Provider Demographics
NPI:1043523723
Name:PONDERA MEDICAL CENTER EYE CLINIC PLLC
Entity Type:Organization
Organization Name:PONDERA MEDICAL CENTER EYE CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-271-3211
Mailing Address - Street 1:403 S DELAWARE ST
Mailing Address - Street 2:
Mailing Address - City:CONRAD
Mailing Address - State:MT
Mailing Address - Zip Code:59425-2310
Mailing Address - Country:US
Mailing Address - Phone:406-278-5331
Mailing Address - Fax:
Practice Address - Street 1:403 S DELAWARE ST
Practice Address - Street 2:
Practice Address - City:CONRAD
Practice Address - State:MT
Practice Address - Zip Code:59425-2310
Practice Address - Country:US
Practice Address - Phone:406-278-5331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PONDERA MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-07-22
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTM011000211Medicare Oscar/Certification