Provider Demographics
NPI:1093929523
Name:YELLOWSTONE DERMATOLOGY PLLP
Entity Type:Organization
Organization Name:YELLOWSTONE DERMATOLOGY PLLP
Other - Org Name:YD SKIN CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:J
Authorized Official - Last Name:HAWK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-238-6115
Mailing Address - Street 1:2900 12TH AVE N
Mailing Address - Street 2:SUITE 240W
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59101-7506
Mailing Address - Country:US
Mailing Address - Phone:406-238-6115
Mailing Address - Fax:406-238-6121
Practice Address - Street 1:2900 12TH AVE N
Practice Address - Street 2:SUITE 240W
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-7506
Practice Address - Country:US
Practice Address - Phone:406-238-6115
Practice Address - Fax:406-238-6121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT0600017482174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000082370Medicare ID - Type Unspecified