Provider Demographics
NPI:1093726796
Name:ROCKY MOUNTAIN EYE SURGERY CENTER INC
Entity Type:Organization
Organization Name:ROCKY MOUNTAIN EYE SURGERY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:406-541-3937
Mailing Address - Street 1:700 W KENT AVE
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-6772
Mailing Address - Country:US
Mailing Address - Phone:406-541-3806
Mailing Address - Fax:406-541-3811
Practice Address - Street 1:700 WEST KENT
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801
Practice Address - Country:US
Practice Address - Phone:406-541-3883
Practice Address - Fax:406-541-3884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT11789261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT3507569Medicaid
MT60112OtherBC
MT5694Medicare ID - Type Unspecified