Provider Demographics
NPI:1073658084
Name:GREAT FALLS SURGICAL ASSOCIATES
Entity Type:Organization
Organization Name:GREAT FALLS SURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:R
Authorized Official - Last Name:MORTENSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-452-0877
Mailing Address - Street 1:400 13TH AVE S
Mailing Address - Street 2:STE 102
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405
Mailing Address - Country:US
Mailing Address - Phone:406-452-0877
Mailing Address - Fax:406-452-2989
Practice Address - Street 1:400 13TH AVE S
Practice Address - Street 2:STE 102
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405
Practice Address - Country:US
Practice Address - Phone:406-452-0877
Practice Address - Fax:406-452-2989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTCK4565OtherRR MEDICARE GROUP NO.
MTCK4565OtherRR MEDICARE GROUP NO.